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OPERATIVE DENTISTRY. 



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A 



PRACTICAL TREATISE 



OPERATIVE DENTISTRY, 



By J. TAFT, 



PROFESSOR OF OPEKATIVE DENTISTRY AND DENTAL HYGIENE IN THE OHIO 
COLLEGE OF DENTAL SURGERY, AND 



PROFESSOR OF PRINCIPLES AND PRACTICE OF OPERATIVE DENTISTRY IN THE DENTAL 
COLLEGE OF THE UNIYEKSITY OF MICHIGAN. 



THIRD EDITION 



OXE HUNDRED AND TWEXTY-EIGHT ILLUSTRATIONS. 



> 






PHILADELPHIA: 

LINDSAY & BLAKISTON. 

1877. 



^^", 



^0^ 






Entered, according to xlct of Congress, in the year 1877, 

BY LINDSAY & BLAKISTON, 

In the office of the Librarian of Congress, at Washington. 



PRESS OF HENRY B. ASHMEAD. 



PKEFAOE. 

THIRD EDITION. 



So great have been the changes, in almost every 
branch of Dental Practice, since the publication of 
the second edition of this work, that the labor in- 
volved in the preparation of a new one has been little 
less than the writing of an entirely new work. 

During the last few years many new instruments, 
appliances and modes of practice, have been intro- 
duced, that have proved very valuable, and are in 
use by the profession, superseding in many cases 
others less efficient, while others, again, have become 
wholly obsolete or comparatively worthless. It has 
therefore become necessary to omit many illustra- 
tions with descriptions of them, but so many more 
have been added that are now regarded as desirable 
and of great practical value, as to greatly increase the 
whole number. 

The general scope and plan of the work has not 
been changed, or any material modification made, 
except adapting it more fully to the present ad- 
vanced state of the science. An Appendix has been 



VIU PREFACE — THIRD EDITION. 

added, presenting some subjects more fully than 
could be satisfactorily done in the body of the work. 
The author, in conclusion, cannot refrain from 
expressing the hope that this edition will be as 
favorably received as the previous ones, and prove 
instrumental in promoting the best interests of the 
profession. 

CiNCiNNATij January^ 1877. 



PEEFACE. 

SECOND EDITION. 



The preparation of the present edition of this work 
has been attended with more labor and effort than 
the author had anticipated. 

The first edition, at the time of its writing, was 
designed to embody and present the principles and 
practice of the profession in the operative depart- 
ment, in its highest attainment. 

Since that time, how^ever, so great have been the 
changes in many points of practice and application of 
principles, that those given as the best, nine years 
ago, are superseded by others and out of use ; so that 
in many particulars the labor has been almost equal 
to the preparation of new matter. 

The object in this, as in the former edition, has 
been to bring the work up to the present status of 
the profession ; and though it has been accomplished 
with many misgivings and consciousness of defects, 
the author is not without hope that it may be of 
value to those preparing to enter the profession, if 
not to those already in it. 



CONTENTS, 



CHAPTER I. 



Introduction, 
Deposits, 
Tartar, 

Its Origin, . 

Points of Deposit, 

Its Effects, . 

Method of Removing it, 
Green Tartar, 

Its Origin, 

Treatment, . 
Irregularity, 

Effects, 
Atrophy, 

The Cause, 

Effects, . 
Exostosis, 

Its Effects, 

The Cause, . 
Denuding, 
Chemical Abrasion, 

The Cause, 
Necrosis of the Teeth, . 

Causes, . 



PAGE 

17 
18 
18 
19 
21 
22 
24 
25 
26 
28 
28 
30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
41 
42 



CHAPTER II. 

Caries of the Teeth, 

Predisposing Causes of Caries, 
Exciting Causes of Caries, 
Comparative Liability to Decay, 
Consequences of Caries, 
Treatment of Caries, 



44 
54 

59 
65 
67 
70 



Xll CONTENTS. 




CHAPTER III. 






PAGE 


General Remarks on Filling, 


75 


Materials for Filling, 


79 


Indestructibility, .... 


79 


Adaptability, 


80 


Hardness, ..... 


■ 80 


Non-conductor, . ' . 


81 


Cohesion, ..... 


81 


Color, . . . 


82 


Lead, ..... 


83 


Tin, . . . . . 


84 


Silver, ..... 


. . 86 


Platinum, . ♦ . 


86 


Gold, . . . 


88 


Various Preparations of Gold, 


90 


Crystal Gold, .... 


91 


Amalgam, . . . ^. 


93 


Oxy-chloride of Zinc, 


96 


Os Artificial, .... 


96 


Non-metallic Materials, 


. . ■ 97 


CHAPTER IV. 




Instruments for Filling, 


. 101 


Heavy Cutting-instruments, 


101 


Drills, ..... 


. 104 


Bur Drills, . . . . . 


104 


Common Drills, 


. 106 


Drill Stocks, . . . ' . 


108 


Excavators, ..... 


.116 


Of the Manufacture of Excavators, 


123 


Filling Instruments, 


. 125 


The File, • - - . 


138 


The Use of the File, . 


. 141 


Mode of Using the File, . 


141 


CHAPTER V. 





Separation of the Teeth, 



145 



CONTENTS. 


Xlll 


CHAPTER VI. 






PACE 


Filling Teeth, ...... 


156 


Examination, ...... 


157 


Opening Cavities, . . . 


IGl 


Removal of Decay, ..... 


162 


Forming Cavities, ..... 


166 


Exclusion of Moisture, ..... 


174 


Saliva Pump, ..... 


176 


Silk Thread, ...... 


179 


Clamps, ...... 


179 


Elastic Strap, ...... 


182 


Wedges, ...... 


182 


Jarvis' Separators, ..... 


183 


Chip Blower, ..... 


187 


Introducing the Filling, . . . 


188 


Cylinder or Block Filing, 


194 


Forming Blocks, . . . • . 


195 


Introducing the Blocks, . 


198 


Pellets, ..•.-.. 


201 


Cohesive Foil, . . ... 


201 


The Mallet, . . . 


205 


Crystal or Sponge Gold, • . . . 


210 


Finishing Fillings, ...... 


213 


CHAPTER YII. 




Classification of Decayed Cavities, .... 


218 


Filling by Classes and Modifications, 


220 


First Class, ..... 


220 


Filling with Foil, ..... 


229 


Cohesive Foil, . . • . 


231 


Crystal Gold, 


233 


Second Class, ..... 


236 


Third Class, ...... 


240 


Fourth Class, ..... 


245 


Fifth Class, ...... 


257 


Special Cases, .... 


263 


The Palatal portion of the Crown broken away, 




leaving the outer portion standing — pulp not 




exposed, ....*. 


264 


Filling large Cavities on the Labial Surfaces of 




the Superior Incisors, 


269 



XIV 



CONTENTS. 



CHAPTER VIII. 





PAGE 


Pathological Conditions, .... 


. 272 


Sensitive Dentine, .... 


272 


Treatment of Inflamed Dentine, 


. 276 


Tannin or Tannic Acid, 


279 


Creosote, or Carbolic Acid. 


. 280 


Nitrate of Silver, 


280 


Chloride of Zinc, .... 


. 282 


Terchloride of Gold. . . . 


284 


Arsenious Acid, .... 


. 284 


Alkaline Caustics, 


287 


CHAPTER IX. 




Exposed Pulps, ...... 


. 289 


Treatment of Exposed Pulps. . 


291 


Destruction of the Pulp, .... 


. 305 


Actual Cautery, .... 


310 


Potential Cautery, .... 


. 311 


Arsenious Acid, .... 


311 


Application, .... 


. 313 


Filling Pulp-cavities and Canals, 


318 


Preparing the Teeth and Roots for Filling, 


. 325 


Dental Periostitis, .... 


335 


Treatment, ..... 


• 338 


Alveolar Abscess, .... 


343 


Treatment, ..... 


. 348 


CIIAPTEll X. 




Pivot Teeth, ..... 


358 


Fitting the Crown, ..... 


. 363 


Attachment of the Crown, 


365 


Metallic Pivots, ..... 


. 370 



Extraction of Teeth, 



CHAPTER XI. 



General Remarks, . 
Indications for Extraction. 
Extracting Instruments, 
The Key, 



376 
376 
383 
385 

387 



CONTENTS. 


XV 






PA6B 


Forceps, 




. 391 


Elevators, 




403 


Hooks, 




. 404 


Screw, . 


. . 


404 


Gum-lancet. . 




. 406 


The Method of Lancing the 


Gums. . 


408 


Extraction of the Teeth, 




. 410 


Superior Incisors. . 


. 


410 


Superior Cuspids, 




. 412 


Superior Bicuspids, 


. 


414 


Superior Molars, 




. 417 


Superior Third Molars, 


. 


420 


Extraction of Roots, . 




. 419 


Inferior Incisors, . 




423 


Inferior Cuspids. 




. 424 


Inferior Bicuspids. 




425 


Inferior Molars, 




. 427 


Inferior Third Molars, 


. 


431 


Extraction preparatory to 


the Insertion of Ar 


ificial 


Dentures. 


. 


432 


Conditions to be observed in 


Extraction, . 


. 434 


CHAPTER XII. 




Accidents in the Extraction of T 


eeth. . 


. 439 


Hemorrhage. 




440 


Treatment, 




. 442 


Fracture of the Alveolus, 




451 


Laceration of the Gums, 


- 


. 453 


Breaking the Teeth, 


. 


453 


Removal of a Wrong Tooth, 




. 454 


Dislocation of the Inferior Maxilla, 


457 


Syncope, 


. 


. 459 


CHAPTER XIII. 




Anaesthetics, 




461 


Ether — Chloroform, 


. 


. 461 


Nitrous Oxide, . 


. 


466 


Local Anaesthesia, . 




. 468 


Congelation, 




469 


Extraction by Electro-magnetism. . 


. 472 


Application. 


. 


473 



XVI CONTENTS. 

APPENDIX. 

PAGE 

Section A. — Dental Caries, ..... 475 

" B. — Dr. Corydon Palmer's Plugging Instruments, 487 

■ " C— Mallets, 495 

Automatic Plugger for Engine, . . 499 

'' D. — Matrices for Proximal Fillings, . . . 502 

" E.— Salicylic Acid, . . . . . 510 



OPERATIVE DENTISTRY. 



CHAPTER I. 

INTRODUCTION. 

Introductory to the following treatise, some con- 
sideration of those conditions and diseases of the 
teeth which require the aid of the dental surgeon, 
seems appropriate. To refer, however, to all of 
these, or to remark at length upon any of them, is 
not consistent with the design of this work, or 
necessary to a proper understanding of the subjects 
proposed. Only those affections which pertain to 
the teeth directly, and the contiguous parts, will 
here be considered; and the latter only so far, in 
the main, as surgical treatment is concerned. Nor 
will the pathology of contiguous parts be introduced; 
for the treatment of these, being mainly therapeutic 
rather than surgical, would involve a discussion of 
questions not within the scope of the present vol- 
ume. Indeed, it is proposed merely to speak of 



18 INTRODUCTION. 

those affections of the teeth which generally suggest 
surgical remedies, and which are implicated more or 
less in the operations described in the following 
pages ) and first, of 

DEPOSITS. 

In this term are included those calcareous forma- 
tions commonly called tartar, a certain coloring 
matter denominated green or brown stain, and such 
other impurities on the teeth as result from neglect, 
the use of tobacco, and like causes. The word 

TARTAR 

implies all calcareous deposits upon the teeth. Of 
this substance there are several varieties, the more 
obvious of which have respect to color, composition 
and consistence. In color, there are all shades, from 
a white, with slight yellow tint, to a jet black ; and 
in consistence, all degrees, from a thick, gummy 
mucus, to nearly the density of the dentine itself. 
The color will, in most cases, be indicative of the 
density, the lightest shade corresponding with the 
softest, and the darkest with the hardest consistence; 
there will, however, be found some variation in this 
respect. The tenacit}^ to the teeth is also in propor- 
tion to the density, the dense and dark adhering 



TARTAR. 19 

most firmly. The character of the surface of the tooth 
upon which the deposit is made, somewhat modifies 
the firmness of attachment. The density of the 
deposit, too, is generally indicative of the rapidity of 
its formation, being in an inverse ratio to this. 

All the varieties of tartar are composed largely of 
the same materials ; though the proportions vary 
much in different cases, — phosphate of lime, fibrin, 
fat, and animal matter, being contained in them all. 
The fact that some varieties are soluble in acids, and 
others not, has been adduced to prove that they are 
entirely different in their composition. This, how- 
ever, is accounted for on another hypothesis : in the 
softer varieties, the phosphate of lime is so protected 
by the fat and the animal matter that, under ordinary 
ckcumstances, acid can not come in contact with it ; 
but the dense varieties are very soluble, because the 
acid readily comes in contact with the calcareous 
material. 

Its Origin. — The calcareous constituents of tartar 
are brought into the mouth in a state of solution in 
the saliva, being secreted from the blood with that 
fluid ; while fats and other animal matter are accumu- 
lated from food, waste from the surface of the mucous 
membrane, and other residual matter from the mucus, 
and perhaps the saliva as well. 

This calcareous material, which consists chiefly of 



20 INTRODUCTION. 

phosphate and carbonate of lime, is precipitated from 
the saliva, by the presence, influence and operation 
of several agencies. 

The saliva, immediately after passing from the 
ducts into the mouth, undergoes a change by absorp- 
tion of oxygen; intermingling with mucus and various 
foreign matters in the oral cavity, and variations of 
temperature, that greatly diminish its solvent power 
for the earthy salts referred to. Precipitation now 
takes place, and lodgment is made upon the most 
susceptible body and point presented. 

Normal saliva always holds in solution more or less 
of this material; and sometimes the agencies above 
referred to are not sufficient to reduce its solvent 
power to the point of precipitation, or letting go the 
material held in solution. It is very probable that 
in some cases the saliva, very soon after being pro- 
jected into the mouth, undergoes change, independ- 
ent of the causes of which mention has been made, 
quite sufficient to permit precipitation of the salts of 
lime it contains. 

Persons of a lymphatic temperament, or a tendency 
toward it, with muscles of a soft, flabby texture, hair 
light, teeth of a rather inferior quality, and a free flow 
of saliva, are most subject to the accumulation of 
tartar ; yet there are conditions of almost all consti- 
tutions in which it is freely formed. That it is pre- 



TARTAR. 21 

cipitated from the saliva, is a fact so easily demon- 
strated and so generally admitted, that it need not 
here be considered. 

Points of Deposit. — The points at which salivary 
calculus is deposited in the greatest quantities upon 
the teeth, are in the vicinity of the orifices of the sali- 
vary ducts ; and hence it is found most abundant on 
the lingual surfaces of the inferior anterior teeth, and 
on the buccal surfaces of the superior molars. Fre- 
quently, also, it collects in considerable quantities 
upon the external surfaces of the inferior front teeth. 
The points to which it most readily attaches, are at 
the necks of the teeth, immediately beneath the free 
margin of the gum, and at the termination of the 
enamel where it is thickest. A nucleus once formed, 
and it encroaches upon the crown of the tooth, if no 
means are employed to prevent its lodgment, at a 
rate determined by the condition of the saliva and 
the changes to which it is subject. 

It is deposited first and most abundantly on the 
necks of the teeth, because here the saliva first comes 
in contact with these organs, and here remains for 
the longest periods and in the largest quantities. 
That it is precipitated very soon after the saliva 
enters the mouth, is evident from the fact that it is 
found collected upon the superior molars, just in the 
vicinity of the orifices of the ducts of Steno, where 



22 INTRODUCTION. 

the saliva cannot be retained for any considerable 
time, by reason of the position, but must very soon 
pass along upon the surfaces of the contiguous teeth, 
on which it is generally found deposited in much 
smaller quantities. Such is the condition of the 
saliva sometimes, either from being surcharged with 
the calcareous material, or from weakness of solvent 
power, that precipitation takes place before elimina- 
tion of the saliva from the ducts ; and so masses of 
the solid substance have been found in the duct 
passages ; and in a few instances have been found 
imbedded in the salivary glands. Tumors are thus 
sometimes found that seem involved in great ob- 
scurity, and occasion intense and prolonged suffering. 
Its Effects. — It exercises no directly injurious influ- 
ence upon the substance of the teeth ; but it is highly 
prejudicial to the parts immediately in connection 
with them, and upon which they depend for support. 
It encroaches upon the gums and alveoli, and causes 
absorption of these important surroundings ; and as 
they become destroyed, its encroachments are con- 
tinued and accelerated. In some constitutions this 
process goes on with little or no annoyance to the 
patient ; while in others, irritation, inflammation, and 
even suppuration of the gums, occur ; and thus their 
destruction is effected in a twofold manner. This 
irritation and inflammation may extend to the mucous 



TARTAR. 23 

membrane, and involve all the adjacent parts. The 
dental periosteum will usually become implicated ; 
periostitis will ensue, and often suppuration, thus 
breaking up the attachments of the teeth even before 
the surroundings are removed. The alveolus, too, 
becomes diseased, and in some instances its death 
and exfoliation result. Salivary calculus, however, 
never induces caries of the teeth, nor even favors it, 
except by inducing disease in the surrounding parts. 
On the contrary, we frequently meet with instances 
of decay entirely arrested and deposit of tartar in 
the cavity. 

Persons of all ages are subject to this affection ; 
those past middle life being most so, and those 
advanced in years sometimes having teeth nearly 
covered with tartar. Occasionally to such an extent 

Fig. 1. 




do the roots become invested with it that the teeth 
drop from the sockets. There are some constitutions 
Avhose diathesis is favorable to a deposition of sali- 
vary calculus through life. Others, again, will be 
entirely exempt from it till some peculiar constitu- 



24 



INTRODUCTION. 



tional change intervenes, when it will begin to be 
rapidly produced. 

Method of Removing it. — The removal of salivary 
calculus is an operation that does not involve a great 
amount of skill, but, with suitable appliances, is 
easily performed. There are two methods of effect- 
ing it; the one, that of scaling and scraping, and 
the other, that of decomposing the deposit by the 
application of an acid. The former is always to be 
preferred ; for, in the latter, the chemical action of 
the acid does not stop with a decomposition of the 
deposit, but, by the same affinity, and nearly as 
readily, attacks the tooth itself. For the successful 
accomplishment of the operation, instruments of 
various forms and curves w^ill be necessary, adapted 

Fig. 2. 




and adjusted to the various shapes and situations of 
the surfaces to be operated upon. The most common 
forms are represented in the above figure. The 



GREEN TARTAR. 25 

blade of the instrument should be applied at a 
slightly obtuse angle with the surface of the tooth, 
just beyond the edge of the deposit next the gum, 
and thus passed under the tartar, scaling it off to 
the point in such a manner as not to cut or abrade 
the enamel. Deposits of this substance on proximal 
surfaces of the teeth are to be carefully observed, 
and removed with instruments of attenuated blades. 
When the thick incrustations have been thus re- 
moved, the surface should then be gently scraped, 
so as entirely to clean off all remaining portions, and 
^terward thoroughly polished with fine pumice, 
Arkansas or rotten-stone, and finished by burnishing. 
During the operation, a frequent employment of the 
toothbrush with water will be required, to cleanse 
the mouth of the detached material and the increased 
secretions ; and, in general, the completion of the 
process will occupy more than one sitting. Since 
this deposit often extends beneath the free margin 
of the gum, much care is necessary to see that it is 
all removed. 

GREEN TARTAR. 

This deposit has been so referred to by writers, 
as to convey the impression that it is of the same 
generic character as salivary calculus. Such a mis- 
apprehension is hardly pardonable. The teeth of 



26 • INTRODUCTION. 

young persons only are subject to this affection, it 
being often found on those of children three or four 
years old ; appears on the labial surfaces of the 
superior front teeth, and in largest quantity near the 
margin of the gum. It is seldom seen on the inferior 
teeth, and only on the anterior surfaces of the 
superior. The color of this deposit varies from a 
light brown to very dark, inclining to green. Wher- 
ever present, the surfaces of the teeth are abraded, 
and when it is of long standing, the entire enamel 
beneath it is destroyed, and the dentine is gradually 
involved in the dissolution. This effect upon the 
teeth is not produced by the coloring matter observed 
upon them, but by an acid in combination with this 
material before it is deposited. The stain is a pre- 
cipitate from this compound, and the acid, leaving 
this, combines with the calcareous ingredients of the 
teeth, to their detriment as above ; but the precipi- 
tate is entirely innocent, so far as decomposition of 
the teeth is concerned. 

Its Origin. — Green tartar, or green stain, doubtless 
has its origin in the mucus, when this is in a particu- 
larly acid condition. That it does not proceed from 
the saliva, is proved by the fact that it is never found 
where there is a free flow of saliva, or where it has 
free access ; but the point of its deposit is where 
the saliva is least frequently present, being raost 



GREEN TARTAR. 27 

abundant in cases in which there is a large relative 
amount of mucus, and this in a very acid condition. 
But the query might arise here, if the mucus of the 
mouth were wholly in that condition, why would not 
the teeth suffer from it elsewhere ? Because, on the 
masticating surfaces of the teeth, the friction of the 
food will prevent it, and on the inner surfaces, the 
friction of the tongue ; besides, wherever there is a 
free flow of saliva, this will have a counteracting 
effect. Decay goes on very rapidly, after it has once 
commenced, upon teeth affected by this deposit. 

There are points of dissimilarity between this 
green pigment or stain and salivary calculus, that it 
may be well to notice. The latter is from the saliva; 
the former from the mucus ; and hence the one exists 
where there is an abundant flow of saliva, and the 
other where the relative quantity of this is small. 
The calculus is deposited when the saliva is in an 
alkaline condition; the stain, when the mucus is very 
acid. The former is deposited in large quantities 
and thick incrustations, and upon the surfaces of the 
teeth, and is easily removed without detriment to 
their substance ; whereas the latter is a thin film, 
barely sufficient to stain the surface, and yet it 
enters into the tooth-substance itself, and cannot be 
removed without detaching some portion of the tooth 
with it. The one seems rather preventive of caries, 



28 INTRODUCTION. 

which does not occur beneath it; but the other is 
highly promotive of decay. With these marked 
features of difference, it is surprising that the two 
should ever have been confounded, since it is so 
important that the distinctive character of each be 
understood, in order to its correct treatment. 

Treatment. — In order to a perfect and final remedy 
for green stain, therapeutic treatment must be com- 
bined with the operative ; but only the latter will be 
here described, which has for its object the removal 
of the deposit, and the rendering of the eroded sur- 
face smooth and polished. There are two or three 
methods of accomplishing this object. When the 
erosion is but slight, it can be effected with Arkansas- 
stone, or pulverized pumice and water, applied with 
a wooden polisher of the proper form till the stain 
disappears, and with the subsequent use of the 
burnisher with a solution of soap. But when the 
erosion is too extensive to be thus reduced, it must 
be cut down with a file, and then finished with stone 
and burnished, as before. And when the erosion is 
extreme, a cutting-instrument may properly precede 
the file. 

IRREGULARITY. 

By this term we imply those variations from a 
beautiful and natural position in which the teeth are 



IRREGULARITY. 29 

SO frequently fouiTd. The principal cause of irregu- 
larity is a disproportion between the size of the arch 
and the space required for the accommodation of the 
teeth. When this disproportion exists, the teeth 
which are first erupted occupy very nearly their 
proper position ; but those which come afterward, are 
more or less disarranged, in proportion to the pre- 
occupation of the space. There are cases in which 
the roots of the temporary teeth are not absorbed, 
and the permanent teeth are erupted out of their true 
position, even when there is room enough for them 
were the former removed. Irregularity is mainly 
confined to the front teeth, and consists in either 
an inward or an outward inclination, and in some 
instances both. Sometimes the incisors are turned 
round in the socket, so that the edge stands at a very 
considerable angle with the proper position. 

The upper teeth are oftener materially disarranged 
than the lower, though the latter frequently exhibit 
some irregularity in front, in consequence of a crowded 
condition. The teeth most liable to be out of position 
are the cuspidate. These, of the teeth of replacement, 
are the last in their eruption ; and it often occurs that 
the arch is previously well-nigh occupied, in which 
case they are thrown outward. When there is any 
irregularity of the bicuspids, it is usually that of an 
inward inclination. The first and second molars are 



30 INTRODUCTION. 

very seldom out of proper position. The third molars, 
however, for want of room, are sometimes thrown 
out toward the cheek, or even prevented from coming 
out at all in any direction. 

Effects. — In all cases, irregularity is favorable to 
decay. It is even maintained by some that the organic 
structure of irregular teeth is less perfect than that 
of regular, because the former are impeded in their 
eruption, and thus impaired. But this, to say the 
least, is questionable ; for it will be remembered that 
the crowns of the teeth are formed and ossified before 
they can be much affected by a crowded state ; and 
it is hardly probable that they could be materially 
modified in their structure after this period. The 
crowns of the teeth are rarely if ever deformed by a 
crowded condition. The principal cause of the liability 
of irregular teeth to decay, is the facility they furnish 
for the lodgment of foreign substances about them, 
and the difiiculty they present to its removal. And, 
again, in irregular teeth, parts are approximated that 
nature did not intend should be brought together. 
Irregularity impairs the speech, impedes the mastica- 
tion, and often distorts the countenance and deforms 
the features. 



ATROPHY. 31 



ATROPHY. 



This affection is characterized by defective spots in 
the enamel, — white, chalk-like, — which scarcely ever 
penetrate the dentine. In these spots there is little 
or nothing of that organic structure exhibited by well- 
formed enamel. They are usually small, but vary 
greatly in number. They are often found arranged 
in transverse rows across the tooth affected. The 
superior incisors are most frequently affected with 
atrophy, though the bicuspids and molars sometimes 
exhibit it. The front upper teeth are attacked by it 
only on the anterior surfaces. 

Instead of the spots, sometimes pits or indenta- 
tions into or through the enamel are found, w^hich 
occasionally run together, so as ultimately to form 
transverse grooves of considerable extent upon the 
teeth. In many cases, where on the eruption of the 
teeth the spots only are presented, the organs are not 
injured, except in appearance, the spots retaining the 
smooth, enamel-like surface during life. In other 
cases, the spot is of such a soft, friable texture, that 
it early crumbles out, leaving the pits above referred 
to. These indentations, however, sometimes exist at 
the first appearance of the tooth, but more frequently 
afterward, being formed by the disintegration of the 
defective portion. 



32 INTRODUCTION. 

Atrophy usually occurs on teeth of good structure, 
short, thick crowns, and rather yellowish color. The 
long, thin, white tooth, of imperfect organization and 
insufficient density, but seldom, if ever, presents an 
atrophied condition. 

The Cause. — It may be difficult to point out the 
precise cause of this affection, but some facts in re- 
gard to it are very obvious. There is in every case 
an obstruction in the development of the enamel at 
the point of defect, and at the time of its organiza- 
tion. In some cases, doubtless, there is a deficient 
amount and an inferior quality of the materials 
elaborated for the upbuilding of the structure ; and 
this is probably the case when the pits exist at the 
eruption of the teeth. In other cases, the requisite 
quantity of materials may be elaborated, and yet 
the vital energy be insufficient to organize it, as in 
the case of the spots referred to. The latter condi- 
tion is more frequent than the former, as is evidenced 
by the more frequent appearance of the spots than 
of the pits. We are led to infer, then, that the 
origin of this affection is for the most part constitu- 
tional, and not local. There are commonly found 
traces of it on all the teeth whose enamel was in 
process of formation at the time of the interruption. 

Any general disturbance, such as to interrupt the 
assimilative process, would be detrimental to the 



ATROPHY. 33 

perfect formation of the tooth. Again, some affec- 
tions may materially affect the organizing power of 
the system without interfering with the assimi- 
lative power. Any disease that interrupts the func- 
tions of the digestive apparatus is prejudicial to 
the process of assimilation; whilst other diseases, 
such, for instance, as those of a febrile character, 
would diminish the vital power, and consequently 
the ability to build up organic structures, without 
interrupting in any special manner the process of 
assimilation. These things are referred to here for 
the purpose of showing under what circumstances 
atrophy of the teeth may occur. 

Effects. — In the best formed teeth, there are no 
unpleasant results from atrophy other than its 
detraction from their beauty, and sometimes being 
the occasion of decay. The spots are unsightly, 
and when the pits are present, they become dark, 
and sometimes black, from deposit, which, by ordi- 
nary means, is difficult of removal. In teeth of 
inferior structure, decay often supervenes in these 
pits, and, extending thence, involves the other parts; 
and anything that will affect the tooth-substance, 
will find a beginning place in these spots. 



34 INTEODUCTION. 



EXOSTOSIS. 



This term, critically defined, implies outgrowth 
from a hone ; but, as applied to the bones generally, 
and particularly to the teeth, it probably conveys 
the idea of growth upon the hone. The affection thus 
denominated is common to all the bones 3 some, 
however, being more frequently attacked by it than 
others. It occurs upon the roots of the teeth, but 
is never developed where there is no periosteum. 
It is so nearly allied in structure and character to 
the cementum that covers the roots of the teeth, that 
it may be regarded as hypertrophy of that tissue. 
The manner of its accumulation is not uniform ; but 
it commonly consists of an enlargement on the point 
of the root, or from the point some distance toward, 
and occasionally all the way to, the neck of the 
tooth. In some cases it extends entirely round the 
root, and in others is confined to one side. It some- 
times results in such an enlargement of the root, 
especially if it is near the point, as to render the 
tooth very difficult of removal. When the root is 
bulb-form, its attachment may be broken up, so as to 
allow it to rotate in the socket, and yet be very 
difficult to remove ; indeed, in some instances, im- 
possible, without cutting away a portion of the 
process. 



EXOSTOSIS. 35 

The density of the deposit does not vary much 
from the normal cementum of the root on which it 
is found, though in this respect there is sometimes 
slight variation ; in a few instances we have found it 
softer than the root proper. The surrounding parts 
are absorbed for its accommodation. The color of 
the substance is slightly yellow, not differing much 
from that of the root itself; but sometimes it ex- 
hibits a semi-translucent appearance. The rate of its 
formation varies considerably, sometimes increasing 
so rapidly as to occasion difficulty, by impingement 
upon the surrounding structure, especially nerve 
branches, and at other times seeming to advance 
very slowly; and frequently it is arrested altogether. 
Roots are often found affected with exostosis that 
have been dead and crownless for a number of years, 
and yet have never, so far as known, given any 
trouble because of the affection. Teeth perfectly 
healthy in other respects may be thus affected. 

Its Effects. — It always increases the difficulty of 
removing the tooth, either by enlargement of the 
point of the root or by deposit upon one side of it, 
causing it to curve; in which latter case the difficulty 
is all the greater, from the impossibility of deter- 
mining the direction of the curve. It sometimes 
produces a diseased condition of the surrounding 
parts — in some instances chronic inflammation — that 



36 INTRODUCTION. 

may continue as long as the tooth remains. Nervous 
affections often result from exostosis, either through 
irritation, caused by pressure on the pulp, or 
through the diseased condition of the surrounding 
parts. The floor of the antrum is sometimes ab- 
sorbed away, in consequence of the -enlargement of 
the point of the root ; and then disease of the lining 
membrane of that cavity may occur. 

TJie Cause. — The cause of this affection is not 
well understood ; though much light has been 
thrown upon it by the researches upon the reproduc- 
tion of bone, and especially so far as the function of 
the periosteum is concerned. It is most probably 
deposited by the periosteum when this is in an 
abnormal condition ; but what peculiar condition, it 
is not clearly ascertained, though some have supposed 
it to be inflammation. It is patent, however, that 
something more than a state of simple inflammation 
exists ; for there is inflammation in numerous in- 
stances without this deposit. Again, in all cases 
where there is periostitis, that state is definitely 
indicated by percussion upon the affected tooth; 
indeed, in the occlusion of the jaws, pain is usually 
experienced. Yet there are found many teeth whose 
roots are subjects of this deposit, that have never 
given any indications, either by pain or otherwise, 
of a diseased condition. 



DENUDING. 37 

This subject is one in wliicli there is room, at least 
so far as dentists are concerned, for more extensive 
observation. 

DENUDING. 

This consists in a wasting away of the enamel of 
the anterior teeth, from the points toward the necks. 
The affection, however, is of too rare occurrence to 
demand extended consideration. The color of the 
enamel is not changed by this process, nor is its 
natural polish impaired by any abrasion. The dentine, 
on becoming exposed by this removal of its natural 
protection or covering, is perfectly smooth, but of a 
yellowish cast, in some cases inclining to brown. 
When the enamel is removed, there seems to be a 
cessation of the destructive process ; for the crowns 
of such teeth will, in many instances, endure for a 
long time — ^indeed, till they are worn down by the 
friction in mastication. 

This wasting process usually begins at the points 
of the teeth, and proceeds toward the necks, on all 
sides, till the enamel is entirely destroyed. Sometimes, 
however, it commences on their labial surfaces ; this 
is particularly the case with the superior anterior, but 
very seldom with the inferior teeth. The affection, 
however, attacks the inferior more frequently than 



S8 INTRODUCTION. 

the superior teeth ; yet it is found assailing both with 
about equal energy. 

The cause of this affection is not well understood, 
though it is generally conceded to be by the opera- 
tion of an acid contained in the mucus ; and this, 
with but little doubt, is the source of the agent ; for 
the destructive process usually occurs where there 
is a large relative amount of this secretion ; but 
that it is an agent of a very decided acid character, 
we are not prepared to affirm. Decay of the 
teeth does not seem to progress with greater rapi- 
dity while this affection exists than at other times; 
and again, the enamel does not present the roughened, 
abraded appearance resulting from the operation of 
any ordinary agent. With these apparently incon- 
gruous facts, it is rather difficult to arrive at a defi- 
nite conclusion as to the precise manner in which this 
condition is produced, or the exact character of the 
agent instrumental in its production. 



CHEMICAL ABRASION. 

This consists in a gradual destruction of the entire 
substance of the crown of the tooth — the enamel and 
the dentine. It is an affection of comparatively rare 
occurrence. It attacks the superior more often than 
the inferior teeth, though both are subject to it. It 



CHEMICAL ABRASION. 39 

begins upon the points of the central incisors, wasting 
them away more rapidly at the median line, from 
which it progresses each way, involving the lateral 
incisors, cuspids, and sometimes the bicuspids, so that 
a curved line is presented by the edges of the teeth, 
of greater or less inclination, according to the rapidity 
of the process. When the superior teeth only are 
affected, the opening between the ends of the upper 
and of the lower front teeth, when closed, is a semi- 
ellipsis. If the inferior teeth are affected, as is some- 
times the case, then the opening will be an ellipsis. 

In the case of Mr. G., the affection had been pro- 
gressing about two years and a half; the wasting 
away extended to the first bicuspids both above and 
below ; and when the jaws were closed, the ends of 
the upper and of the lower central teeth were about 
one-third of an inch asunder, and the opening was of 
the elliptical form. It was a mystery to him. Two 
years and a half before, his anterior teeth shut close 
together on the ends. He had not used them in the 
mastication of his food, for his molar teeth were all 
good, and sufficient for this purpose ; and, moreover, 
it had been impossible for him to use them in masti- 
cation, since he could not bring them together ; and 
he had not been in the habit of putting any hard 
substance between them. 

The Cause. — The cause of this affection, like that 



40 INTRODUCTION. 

of denuding^ is not well understood. It is supposed, 
however, to be induced by an acid contained in the 
mucus. If this supposition is correct, it must be 
some acid with whose nature we are but little, if at 
all, acquainted ; or, if any ordinary acid, it certainly 
must be modified by very peculiar circumstances, so 
that it effects a solution of both the animal and the 
earthy constituents. The surface upon which it acts 
is always perfectly smooth and polished, never pre- 
senting that roughened and abraded appearance caused 
by the action of any ordinary acid upon enamel or 
dentine. And again, if this affection results from the 
operation of an acid in the mucus, why does not this 
acid, to some extent at least, affect the teeth at other 
points ? Such is not the fact ; and caries that has 
previously commenced at other points on the teeth, 
does not progress more rapidly during the existence 
of this disease than before ; but it certainly would 
if there were a large quantity of acid in the mucus. 

It has been supposed that the mucous follicles of 
that part of the tongue which comes in contact with 
the teeth at the affected part, are the agents that 
produce the disease. Of this, however, there is not 
evidence sufficient to warrant an adoption of the 
theory. The cupping of the molars and bicuspids 
bears strong indications of being an analogous process, 
and yet no such influence can there operate for its 



NECROSIS OF THE TEETH. 41 

accomplishment. We have no theory on this subject 
to present, regarding it as still an open field for 
investigation. There can be little doubt, however, 
that the cause of denuding, of chemical abrasion, and 
of cupping, has its origin in the constitution, is not 
merely local, and may be removed, and the affection 
arrested, chiefly by constitutional treatment. 

■ NECROSIS OF THE TEETH. 

By this term is understood the death of the part 
affected. It has been remarked that the condition is 
similar to mortification in the soft parts of the sys- 
tem. But in the latter there occurs a change of 
structure ; whereas, in the bones, and particularly in 
the teeth, there is not necessarily any immediate 
structural change consequent on the loss of vitality. 
The teeth have their organic connection with the 
surrounding parts by the external and the internal 
periosteum and the pulp ; their crowns depend chiefly 
for vitality upon the internal organism, as is evident 
from the total loss of sensibility in them immediately' 
after the destruction of the pulp. 

Necrosis of the teeth differs from that of the other 
bones in some particulars, one of the most obvious of 
which is, that in the former there is no exfoliation, 
the living structure not having the power to throw 



42 INTRODUCTION. 

off the dead or necrosed portion. Again, a dead part 
in contact with the living does not materially affect 
it. The roots of the teeth depending for their vitality 
upon both their internal and their external connec- 
tions, the former of these connections may be 
destroyed without materially affecting the latter. 
Thus, a tooth may be partially necrosed, — that is, 
vital in one part and dead in another, — without im- 
mediate injury to the living portion, and without 
separation of the living from the dead. It is a happy 
provision that the analogy between the teeth and 
the other bones does not, in this respect, obtain ; for 
if it did, we should find the crowns of the teeth 
separated from the roots in all cases, immediately 
after the death of the pulp. 

There results but little change of color to the teeth 
from necrosis, unless coloring matter is absorbed by 
the dentine from the decomposed pulp ; though of 
course the lifelike lustre and appearance of the 
living teeth are not present. Total necrosis destroys 
the entire organic connection of the teeth with the 
surrounding parts, in which case they are very soon 
expelled from their sockets as useless. 

Causes. — Caries is a very common cause of ne- 
crosis, especially the partial form of it to which 
reference is made above. Protracted fever, or dis- 
eases of any kind that diminish the vitality of the 



NECROSIS OF THE TEETH. 43 

constitution, will in a corresponding degree diminish 
that of the teeth, and sometimes destroy it entirely. 
Excessive medication, especially with mercurials, 
will sometimes produce partial, and occasionally 
total, necrosis, as will also sometimes blows or 
yiolent shocks, when these are not sufficient to 
displace the teeth. Sudden and extreme thermal 
changes have been reckoned causes of this affection ; 
but it may well be doubted whether they are ade- 
quate, without the concurrence of other influences. 



CHAPTER II. 

CARIES OF THE TEETH. 

Notwithstanding the teeth are so important in the 
human economy, having functions so various and so 
extensive to perform, they are greatly neglected in 
most instances, and in many subjected to positive 
violence ; as, for example, in crushing or biting hard 
substances, sustaining weights, and suffering severe 
blows, sudden extremes of temperature, bungling 
dental operations, etc. Very few give that attention 
to these organs which is requisite to preserve them 
from injurious influences ; and, owing to artificial 
modes of life, and consequent impairment of health, 
this is often difficult to do. Indeed, these influences 
are frequently not known, and the causes of disease 
in the teeth not explored. 

Such is the truth, to some extent, in regard to 
caries ; though this affection is more generally a 
result of conditions well understood. The dentine 
is affected more frequently by caries than by any 
other form of disease. It is both frequent in occur- 
rence and fatal in tendency. Scarcely any that 



CARIES OF THE TEETH, 45 

have attained maturity are exempt from its ravages. 
It is a disease which the vital forces, owing to the 
nature of the tissue, can but feebly withstand, at 
least with far less efficiency than in more highly 
organized structures ; and the restorative process is 
wholly inoperative here. Some maintain that softened 
dentine does in many cases regain its normal density; 
but this cannot be, unless it retains its vitality. But 
any agent possessed of sufficient energy to decom- 
pose the dentine, will destroy its vitality; yet a 
partial removal of lime salts is not always incom- 
patible with, or destructive to, vitality; in such cases 
the normal density of the affected part may be fully 
restored; and even increased growth has in a few 
instances been observed. In decay, there is a lack 
of vital power to maintain the integrity of the 
organic structure, or there is the action of some agent 
having an affinity for a certain part of the dentine 
more potent than that vital power. In either case, 
the vitality is destroyed. In an organized structure, 
removal of one of its essential constituents occasions 
a loss of vitality. 

Caries usually makes its first attack upon the 
dentine, and progresses most rapidly in the direction 
of the tubuli. There are variations from this course; 
as, for example, in the large superficial caries on the 
labial surfaces of the superior incisors. In many 



46 CAEIES OF THE TEETH. 

cases, too, it advances immediately beneath the 
enamel. Portions of the dentine imperfectly pro- 
tected by the enamel, on account either of an injured 
condition or of an imperfect formation of the latter, 
are liable to be attacked by this disease ; and points 
that, by their location or any other unfavorable cir- 
cumstance, retain injurious agents in contact with the 
tooth, are very subject to decay. ^ I 

The attack and progress of caries are modified by 
the constitution of the teeth. These may be defec- 
tive, either originally or accidentally. Original de- 
fectiveness extends to all the teeth of the same 
individual, whilst accidental exists only as to some 
of the teeth in the same mouth, and these only at 
particular points. Such conditions are peculiarly 
favorable for the attack of caries. When the whole 
crown of the tooth is imperfectly organized, the 
decay will advance with uniform rapidity, under the 
influence of uniformly persistent agents, till the 
whole is destroyed. But when it is only a portion of 
the tooth, the caries after a time becomes retarded 
in its progress, and in some cases checked altogether. 

Among the circumstances which modify the pro- 
gress of this disease, are, a change of the condition 
or character of the agencies producing it, and an 
increase or diminution of the amount of such agen- 
cies. The progress of caries will also be governed 



CARIES OF THE TEETH. 47 

somewhat by the age of the person whose teeth it 
attacks, as well as by the jDeculiar constitution of the 
organs themselves ; for, in regard to constitution, 
they present an almost infinite variety, the relative 
proportions of their constituents being exceedingly 
various, even in persons of the same age, and con- 
tinually A^arying in the same person at different ages. 
There is a constant change going on, the calcareous 
elements usually increasing, and the animal decreas- 
ing. But a proper relative amount of elements may 
be elaborated, and yet a defective organization exist. 
This condition arises from defective organizing power, 
or from a failure in arrangement and combination of 
the materials, and is dependent entirely on acci- 
dental causes. In vital energy, indeed, the teeth 
exhibit great diversity; and this corresponds with, 
and to some extent depends upon, the vital energy 
of the general constitution. Dead dentine is decom- 
posed more readily than living ; and hence the con- 
clusion that vitality resists caries, and that this 
resistance corresponds w^ith the vigor of the vitality. 
The points most frequently attacked by caries are 
the proximal surfaces of the teeth, the indentations 
and fissures on the masticating surfaces of the molars 
and bicuspids, the longitudinal depressions on the 
buccal and palatal walls of the molars, and the necks 
of the teeth at the termination of the ennmel. On 



48 CARIES OF THE TEETH. 

the proximal surfaces, the enamel is thinner than 
elsewhere ; and the situation is peculiarly favorable 
for the accumulation and retention of injurious 
agents. The union of the enamel in the fissures 
and indentations of the crowns of the molars is 
often imperfect; and thus there is a way of entrance 
for vitiated fluids to the dentine. Decay is found 
at the terminations or intersections of these fissures 
earlier than at any intermediate points. The inden- 
tations, or grooves, on the sides of the teeth are 
usually attacked by caries at that point next to the 
neck; Less frequently, the disorder is exhibited at 
the neck, just beneath the border of the enamel, 
under which it burrows with a transverse extension. 
The order in which the elements are removed is 
governed by the nature of the agent which effects 
the decomposition; and this is usually one having 
an affinity for the calcareous elements strong enough 
to destroy the texture of the dentine, and remove 
the earthy portion. Those acids which have an 
affinity for the lime of the dentine, produce its 
decomposition in this manner. When the decay is 
thus caused, the portion remaining in the cavity is 
soft, and approximates the gelatinous condition as 
the calcareous material is abstracted. Agents of a 
different character, too, often produce decay. Alka- 
lies will act upon the animal portion of the dentine, 



CARIES OF THE TEETH. 49 

and remoTe it ; and in caries thus produced, the 
residue is friable and chalk-like. 

In other cases the constituents are simultaneously 
removed. Nitric acid will cause an entire breaking- 
up of both the earthy and the animal constituents. 

The dentine outside of the decay may be in an 
inflamed and irritable condition, so that the contact 
of an instrument with the decayed portion will 
produce pain : and thus we may be led falsely to 
conclude that the softened dentine is sensitive ; and, 
indeed, it is maintained that in some cases the 
partially decomposed dentine is so, on the suppo- 
sition that a small portion of the calcareous elements 
may be removed, and yet the vitality of the part 
not be destroyed. 

The progress of caries is far more rapid in the 
crowns of the teeth than in the roots, for the reason 
that the former are more exposed to the influences 
of external injuries. It is true that the crowns are 
covered by enamel, which is designed to shield the 
dentine from injury; but this is often defective, 
and on it are accumulated agents that it cannot 
resist even when it is perfect, so that the enamel 
itself is sometimes decomposed. The roots, too, 
possess a higher degree of vitality than the crowns, 
and their ability to resist the encroachments of 
decay is correspondingly greater; and hence we 



50 CARIES OF THE TEETH. 

often find the roots of teeth solid and free from 
decay, the crowns of which have been removed by 
rapid decomposition. Injurious substances are some- 
times pressed into contact with the dentine through 
defects in the enamel, or under its projections, and 
there retained till their mischievous effect is pro- 
duced. 

It is maintained by some writers that caries is 
contagious. Dr. Koecker was of this opinion. The 
question, then, is, whether there is any property in 
the decayed dentine of one tooth capable of pro- 
ducing the same condition in the healthy dentine of 
another? The residue of abnormal dentine in the 
soft decay consists of the animal elements and a 
small portion of earthy material; and in decay in 
which the gelatinous constituent is abstracted, the 
remainder is chalk-like, consisting mainly of phos- 
phate of lime. In neither of these is there anything 
that can possibly operate on the healthy dentine. 
There is one thing here, however, that is worthy of 
remark, and that has perhaps led to the mistaken 
notion that caries is contagious : decayed dentine 
will absorb and retain fluids that injuriously affect 
sound dentine ; and when the decay is on the 
proximal portion, two teeth are subject to the same 
exciting cause. But it is seldom that two teeth 
thus situated are both in the same stage of decay — 



CARIES OF THE TEETH. 51 

a fact principally attributable to the difference in 
their constitution. The decay of the teeth in pairs 
has also been adduced as evidence of the contagious 
character of the disease. This, however, results 
from the fact that the pairs are formed at the same 
time, are subject to the same influences in their 
formation, and hence are constituted alike ; and if one- 
of the pair is defective, the other will probably be 
in a like condition. When there is a vitiation of the 
saliva or mucus, they will be similarly affected. In 
no common acceptation of the term contagious can 
it be applied to caries of the teeth. 

The color of caries is exceedingly various, from that 
of healthy dentine, through every intermediate shade, 
to jet black. The rate of the progress is indicated by 
the color of the decay, being slower as this is darker, 
so that when the decay becomes almost stationary, 
the affected portion is usually black. The degrees of 
color are differently enumerated by different writers ; 
as, by Koecker five, by others seven, and so on. Three, 
however, are sufficient for our purpose : white, brown, 
and black. The sensitiveness of the dentine is greatest 
in teeth affected by the white decay, and usually 
decreases as the color darkens ; though there are 
exceptions to this rule, for occasionally the teeth 
affected by dark decay are quite sensitive. The 
light-colored decay is more difficult to arrest than the 



52 CARIES OF THE TEETH. 

dark. In many cases of the former, filling seems 
hardly to retard its progress ; whereas in the latter, 
by proper filling, the advance of the decay may be 
checked altogether. The cause of the dark color of 
caries is not perfectly understood, but is probably 
owing to the carbonization of the animal portion. 

The opinion is entertained by some that this dark 
material protects the dentine from the influence of 
injurious agents. But this is most probably not 
correct, at least to any perceivable extent. If it does 
thus serve as a protection, its removal would subject 
the dentine to a renewed attack of caries, which 
experience assures us it does not do. Those who main- 
tain this opinion, refer, in support of it, to the fact 
that when a deposit of oxyd of silver is made upon 
a decay of light color, by the use of nitrate of silver, 
the progress of the decay is thereby retarded. This 
retardal, however, is effected more probably by a 
change in the character of the decay than by any 
protection afforded by the coating of oxyd of silver. 

Some sensitiveness commonly accompanies caries. 
It does not often amount to pain, but is rather a sense 
of uneasiness ; yet from change of temperature, or 
contact of acids or hard substances, intense pain may 
be produced. Dr. Koecker remarks that caries is 
most tender in its first stages ; and Dr. Cone that 
when a tooth is attacked by it, the sensitiveness is 



CARIES OF THE TEETH. 53 

increased. The surface of the dentine, or that part 
united to the enamel, is susceptible of the most acute 
sensitiveness. When there is inflammation of the 
dentine, intense pain may be produced by the contact 
of an instrument, in a cavity of decay, at the line of 
union of the dentine with the enamel, with very 
little sensitiveness present elsewhere in the cavity. 
Sensitiveness of a uniform character sometimes per- 
vades all parts of the cavity, while at other times 
it may be very intense at one point, and very slight 
or entirely absent at any other. A thin lamina of the 
dentine lining the whole cavity may be uniformly 
sensitive, and in some cases sensitiveness involves 
the entire body of the dentine. 

By means of this sensitiveness, warning is trans- 
mitted to the pulp, which emits osseous material with 
increased energy ; and thus a process of filling up the 
natural cavity of the tooth is instituted, that the decay 
may not encroach upon the pulp. But this warning 
may in some degree be transmitted to the pulp 
though there be no appreciable increase of sensitive- 
ness. 

This sensitiveness is modified by the character of 
the teeth, the nature of the decay, and the state of 
the patient's constitution. The teeth of the same 
person will be more sensitive at one time than at 
another, because of a greater irritability of the nervous 



54 CARIES OF thJ: teeth. 

system. Those teeth which decay most rapidly are 
usually most sensitive ; though in teeth whose vitality 
is lost considerably in advance of their decay, there 
is no perceptible sensitiveness at all. Except in such 
cases as last mentioned, the whitest and most rapid 
decay has most sensitiveness, the brown much less, 
and the black scarcely any. 



PREDISPOSING CAUSES OF CARIES. 

The causes of caries of the teeth may be considered 
under two general divisions — predisposing and excit- 
ing. Of the former some are original, others acci- 
dental. The original development of the constitution 
may be defective, either from original or from acciden- 
tal defect in the parent, but more certainly from the 
former. Constitutional characteristics are transmis- 
sible, and a defect is as surely hereditary as anything 
else. In the fetus, during gestation, germs may have 
originated from which perfect organs can never be 
developed, and these germs may be more or less 
defective according to the constitutional condition of 
the mother, or according to accidental conditions to 
which she may be subject, and which may seriously 
affect the fetus. After birth, too, the child is exposed 
to injurious impressions, which will, to a greater or 
less degree, render the development defective ; as 



PREDISPOSING CAUSES OF CARIES. 55 

imperfect nourishment and the diseases and functional 
derangements peculiar to childhood. A diseased 
condition, or functional derangement, will interrupt 
the proper elimination and perfect upbuilding of the 
materials necessary for the perfect structure ; and 
indeed anything that will disturb the equilibrium of 
action in the system may be detrimental to the 
teeth. 

In some instances the teeth will exhibit the pecu- 
liarities of the mother, and in others those of the 
father, while sometimes they simulate those of both 
parents ; and when the parental imprint is thus found 
stamped on the teeth, it will also be found that those 
of the same class decay at the same points and at 
about the same age as in the parent. In such cases 
the defect is manifestly hereditary; it cannot be 
accidental : the coincidences thus constantly occur- 
ring preclude any other conclusion. Hereditary taint, 
then, may be regarded as a predisposing cause of 
caries. 

Impaired vitality is another predisposing cause ; 
and not only impaired vitality of the teeth and con- 
tiguous parts, but also that of the general system. 
Indeed, the vital vigor of the teeth depends upon 
that of the general system, and, when there is no 
local adverse influence at work, corresponds with it ; 
so that when the general system is in the most 



56 CARIES OF THE TEETH. 

healthy condition, the teeth possess the greatest 
power of resistance to deleterious agencies. This 
resisting power is, at best, comparatively feeble ; but 
its feebleness is to some extent compensated by the 
peculiar structure of the teeth, w^hich are less liable 
to decomposition than any other part of the human 
body. Yet the integrity of these organs depends 
much on the maintenance of a healthy vitality, and 
this on that of the general system. A dead tooth 
will decay far more rapidly than a living one in simi- 
lar circumstances ; and hence the conclusion that 
vitality resists injurious agents, and that the resist- 
ance will be in proportion to the vitality. 

All febrile conditions promote and facilitate decay, 
and frequently in two ways : by diminishing vitality, 
and by changing the secretions of the mouth so that 
these act injuriously upon the teeth. Accompanying 
such conditions there is generally inflammation of the 
dentine ; and in such cases this always partakes of 
the general disorder, so as to become very susceptible 
to injury. All diseases, indeed, that impair the 
vitality and change the secretions, may be considered 
predisposing causes of decay, and some even more ; 
dyspepsia, for instance, being not only predisposing, 
but also exciting, since it prepares in the stomach an 
acid that is almost continually thrown upon the teeth, 
and that acts upon them with great energy. Resi- 



PREDISPOSING CAUSES OF CARIES. 57 

dence in miasmatic regions is also a predisposing 
cause, inducing unfavorable conditions. 

Diminished vitality may result either from consti- 
tutional or from local causes. These latter are such 
as produce an irritable or diseased condition of the 
contiguous parts, or an abnormal condition of the den- 
tine, without the power to effect its decomposition. 
Local causes of a diminution of vitality are not in 
their character so formidable, and not so difiicult to 
control, as those which are constitutional. 

Many medicinal agents are regarded as predispos- 
ing causes of caries ; and among these, mercurials 
occupy a prominent place. They operate by vitiating 
the secretions of the mouth, and producing an abnor- 
mal condition of the periosteum about the roots of 
teeth, the mucous follicles, and the salivary glands. 
Some entertain the opinion that the abnormal action 
of the absorbents induced by mercurials predisposes 
to decay. 

Dental operations performed at an improper time, 
and in an improper manner, may be reckoned among 
the predisposing causes of caries. The vitality of the 
teeth may be thus impaired, or a diseased condition 
established, or the part operated upon may be per- 
mitted to remain rough, so that foreign substances 
will be retained, and, becoming vitiated, produce a 
deleterious effect. Often, from an improper use of 



58 CARIES OF THE TEETH. 

the file, extensive inflammation of the dentine super- 
venes, which is sometimes followed by death of the 
tooth, and by disease of the contiguous parts. Arti- 
ficial substitutes, imperfectly adapted, are in many 
instances the occasion of caries ; not that clasps or 
the edges of the plate tend directly to injure the 
tooth, but the agencies superinduced by them do, 
and especially when the material used is not of the 
right quality. 

Lack of proper exercise in mastication induces a 
condition favorable to decay, both by favoring the 
action of injurious agents upon the teeth and by with- 
holding the stimulus of normal exercise. Tartar and 
other deleterious substances are much more rapidly 
deposited when the teeth are idle. 

The teeth cannot with impunity undergo great 
and sudden transitions of temperature, or even such 
variations as may be endured by the surrounding 
parts. By these, inflammation of the dentine may 
be induced, and the vitality of the teeth dimin- 
ished. And in friable teeth, checking of the enamel 
may occur, and thus a condition arise that will facili- 
tate decay. 



EXCITIXG CAUSES OF CARIES. 59 

EXCITING CAUSES OF CARIES. 

When there is a predisposition to caries, any of the 
exciting causes act with more effect. Well-organized 
teeth; of unimpaired health and vitality; withstand 
influences that in less favorable circumstances des- 
troy them in a very short time. The immediate 
cause of decay is the action of agents chemically upon 
the teeth. It is not here proposed to enter upon an 
investigation of the manner in which these various 
agents operate, for that would open up a large field 
for consideration — a field outside of the province of 
this work. The sources of these, however, are several: 
as. vitiated secretions of the mouth ; the saliva, and 
the mucus ; abnormal secretion from the stomach ; 
decomposition of animal and vegetable substances in 
the mouth, etc. 

The natural state of the mucus is acid, but that of 
the saliva alkaline ; so that these secretions counter- 
act each other ; but when the saliva and the mucus 
are both acid, the teeth must suffer. These secre- 
tions may become vitiated through inability of the 
glands; from disease or an enfeebled condition, per- 
fectly to perform their functions ; or the blood may 
be in an abnormal state, and the glands unable, on 
that account, though they were healthy, — as they 
seldom are in such case. — to elaborate health v saliva. 



60 ■ CARIES OF THE TEETH. 

When the fountain is corrupt, the stream cannot be 
pure. Thus, anything that produces a diseased con- 
dition of the blood tends to the decay of the teeth ; 
and such diseased condition often has a directly 
injurious effect on the secretive apparatus, and so 
works a double harm. 

But to the theory of the pernicious influence of the 
saliva, it may be objected, that if it were true, all 
parts of the teeth would be alike affected. This 
objection, however, will lose its force when it is con- 
sidered that the teeth, in many cases, are not equally 
well organized in all their parts; that some parts are 
not so well protected as others ; and that between the 
teeth there is room for the retention of saliva and 
foreign substances, which there combine their influ- 
ence upon them. When there is a great quantity of 
viscid saliva constantly flowing, the teeth decay very 
rapidly. The decay is of a light color — so light, 
indeed, that in many instances it is difficult to dis- 
tinguish it, by this, from undecomposed dentine. 

The gastric fluid often becomes deranged by irrita- 
tion or disease of the stomach, so that the function 
of the latter is very imperfectly performed, and fer- 
mentation of the food occurs, evolving agents that 
injuriously affect the teeth. In dyspepsia, such 
agents are often brought in contact with the teeth by 
eructation and vomiting; and the diseased gastric 



EXCITING CAUSES OF CARIES. 61 

fluid, which contains a large proportion of hydro- 
chloric acid, is also thus brought in contact with them, 
acting with great violence. After food commingled 
with this secretion is ejected from the stomach, the 
teeth will be found eroded over all their surfaces. 
Dyspeptics wdll appreciate this remark. In such 
cases, if the teeth are not of superior organization, 
they are destroyed in a short time. Their surfaces, 
thus roughened, afford a lodgment for foreign sub- 
stances on all parts. 

The most common agents, however, that injure 
the teeth, are originated in the mouth by the decom- 
position of animal and vegetable matter. By this 
process, elements are eliminated that form new 
combinations, and these operate with energy in the 
destruction of the teeth. Favorable conditions exist 
in the mouth for such decomposition, and also for 
such new combinations ; for there is a sufficient 
amount of heat and moisture, — for both of these, 
especially the former, facilitate the action of any 
acid upon the dentine. The character of the saliva 
and mucus will very much modify the decomposition 
of foreign substances in the mouth. If these secre- 
tions are both acid, the decomposition will be much 
more rapid, and more potent in its effect. 

Again, it is sometimes the case that the salivary 
glands are comparatively inactive, except when spe- 



62 CARIES OF THE TEETH. 

cially excitedj and yet the mucous glands still effi- 
cient, eliminating their secretion; so that the mouth 
assumes an acid condition, because there is not saliva 
sufficient to neutralize the mucus, in which condition 
decomposition of foreign substances would be greatly 
accelerated. There are many cases, however, in 
which the flow of saliva is copious, and yet the 
decay very rapid, which is in consequence of an 
acid condition of both secretions, or of a rapid 
decomposition of foreign substances in the mouth. 

There are acids taken with the food that act 
directly upon the teeth; as acetic acid, or vinegar. 
Professor Westcot says : " Acetic and citric acids so 
corroded the enamel in forty-eight hours, that much 
of it was easily removed with the finger-nail." And 
"Malic acid, or the acid of apples, in its concentrated 
state, also acts promptly upon the teeth." Now, 
these acids, in the use of many kinds of food, are 
brought into frequent contact with the teeth. In 
the manufacture of vinegar, sulphuric acid is often 
employed; so that in this article of food we have 
that acid either alone or combined with the acetic, 
the former acting with greater energy upon the teeth 
than the latter. Acetic acid also facilitates the fer- 
mentation of food retained in the mouth, and thus 
reproduces itself in abundance. 

After eating apples that contain a great amount of 



EXCITING CAUSES OF CARIES. 63 

malic acid, the teeth will be found corroded over all 
their surfaces. This acid, as well as the others, 
affects the enamel somewhat, and when the latter is 
very thin, though it may not be all removed from 
any particular point, yet its integrity will be 
destroyed, so as to be readily fractured, thus admit- 
ting injurious agents to contact with the dentine, 
which is much more susceptible of injury from acids 
than the enamel : points imperfectly protected by 
this are violently attacked by acetic, malic, and 
sulphuric acids, especially when in the nascent state. 
In decayed cavities these agents produce rapid 
results. They should be as much as possible avoided, 
and, when necessarily used, should be removed from 
the teeth by cleaning with great care. It would be 
safest to employ some neutralizing agent after the 
use of any acids with food. During mastication, 
there is an increased secretion of saliva, which, if in 
a healthy state, will tend to neutralize any acid that 
may at the time be present, and also, by its flow, to 
remove foreign substances from the mouth. 

Salts may be decomposed in the mouth, and their 
acids act upon the teeth ; as when the acid of the 
salt has a stronger affinity for any element of the 
tooth-bone than for the base with which it is com- 
bined. Many medical preparations contain agents 
peculiarly deleterious to the teeth, acids being espe- 



64 CARIES OF THE TEETH. 

daily in requisition for these, and oftentimes in 
considerable quantities. The acids most commonly 
thus administered are the hydrochloric, the nitric, 
the sulphuric, the acetic, the tartaric, and the citric, 
any one of which will produce direct and rapid 
corrosion of the dentine, even when unaided by the 
temperature of the mouth. For a fuller and more 
explicit presentation of the points here briefly hinted 
at, see Appendix at the close of this volume. Sec. A. 
These acids are often administered by physicians 
without any regard to their nature or their influence 
upon the teeth. Sometimes, however, they are given 
through a tube, though this method generally does 
not amount to much as a precautionary measure, for 
in most instances the fluid comes in contact with all 
parts of the mouth. A subsequent rinsing of the 
mouth with water effects only a dilution, not an 
entire removal of the acid. In order wholly to 
counteract their injurious influence upon the teeth, 
an alkaline solution should be used after the adminis- 
tration of such medicines. 

Galvanic action is a cause of decay of the teeth, 
only so far as it is a means of decomposing com- 
pounds in the mouth, and the elements of which, 
according to the laws of affinity, form other com- 
pounds prejudicial to the teeth. The elements 
hydrogen, nitrogen, and oxygen, may thus be set 



EXCITING CAUSES OF CARIES. 65 

free from animal and vegetable substances, when 
they will at once seek other elements with which to 
combine ; and the character of the combinations will 
be determined by the nature of the elements, and by 
the attendant circumstances. These compounds will 
frequently be of an acid character. 

Such an arrangement may exist as will maintain 
a constant galvanic action, whose legitimate effects 
will be as constant upon the teeth ; and this cease- 
less process cannot but make its mark. It is a 
favorable arrangement for galvanic action when there 
are two or three kinds of metals in the mouth at 
once, particularly if these are such as differ in their 
affinities for oxygen, and in their electric conditions. 
In some cases three or four kinds of metals are 
employed in filling teeth of the same mouth; in 
some, fillings of one metal and a plate of another ; 
and in others, plates of so low a carat are used that 
they oxydize rapidly in the mouth, without the aid 
of any other metal. 

COMPARATIVE LIABILITY TO DECAY. 

All classes of teeth are not alike liable to decay. 
Their difference in this respect may arise from a dis- 
similarity in their organic structure, the best organized 
being the most capable of resisting disease ; or from 



66 CARIES OF THE TEETH. 

a concentration of the destructive agency upon the 
tooth first affected. The first molars are much more 
liable to decay than any other teeth, since they are 
less perfectly developed than those formed at a later 
period of life. They are the first permanent teeth 
erupted, and are subjected to all the irritating condi- 
tions consequent on the removal of the temporary 
and the development and eruption of the permanent 
teeth. But these conditions in many cases produce no 
apparent injury upon them, they maintaining their 
integrity till all the other permanent teeth appear, 
and then decaying earlier than any others. In such 
cases, the decay is a result of influences more potent 
than those occurring on the eruption of the other 
teeth. 

After the first, the second molars are most subject 
to caries ; and after these the second bicuspids. The 
latter two classes doubtless are so subject, more from 
the facility they afi'ord to the lodgment of deleterious 
substances than from a relatively imperfect organiza- 
tion. Besides, from six to fifteen years of age, the 
teeth are less appreciated and less cared for than at 
a later period of life. The next most liable to decay 
are the third molars. Then follow in order the first 
bicuspids, the lateral incisors, the central incisors, and 
the cuspids. Herewith are appended, in tabular form, 
one thousand cases of decayed teeth, as observed 



28, 


or 3| 


24, 


or 2\ 


87, 


or 8| 


134, 


orl3i 


370, 


or 37 


218, 


or22f 


102, 


orlOi 



CONSEQUENCES OF CARIES. 67 

under ordinary circumstances, exhibiting the number 
and per cent, of these in each class : — 

26, or 2| per cent., in central incisors. 

" in lateral incisors. 

" in canines. 

" in first bicuspids. 

" in second bicuspids. 

" in first molars. 

" in second molars. 

'' in third molars. 

Of these, a large proportion were removed for relief 
from disease originating in caries of the dental tissue. 
In general, the superior teeth are liable to decay 
earlier and more rapidly than the inferior. 

CONSEQUENCES OF CARIES. 

It is here proposed to refer only to some of the 
more common results of this affection, one of the most 
obvious of which is the exposure of the pulp of the 
tooth, on which exposure disease ensues, and finally 
death. During this diseased condition of the pulp, 
there occurs that very peculiar and well-known sen- 
sation commonly denominated toothache. As well as 
the destruction of the pulp, the entire destruction of 
the crown of the tooth is the inevitable consequence 
of caries, unless arrested in its progress. After the 
destruction of the pulp and the lining membrane, 



68 CARIES OF THE TEETH. 

the external periosteum in many cases becomes 
involved, the affection being but an extension of that 
which destroys the internal periosteum. Inflamma- 
tion and suppuration are of common occurrence, by 
which a discharge is established from between the 
margin of the gum and the neck of the tooth, or 
through a fistulous opening in the process and the 
gum, as is the case when an abscess is formed at the 
point of a root. 

A diseased condition of the alveolar process is in 
many instances produced by diseased and dead teeth, 
necrosis and exfoliation of considerable portions being 
sometimes the result. Indeed, extensive caries of 
the jaw is occasionally thus produced. Disease of 
the antrum, too, is very generally induced or greatly 
aggravated by the same cause. Tumors, sometimes 
of a malignant character, connected either with the 
bony or with the soft parts, not unfrequently spring 
from this source, particularly in constitutions of a 
cancerous diathesis. Great nervous derangement may 
result, either in whole or in part, from decayed teeth, 
as does very frequently facial neuralgia, which is 
sometimes confined to a single nerve-branch in the 
immediate vicinity of the irritating cause, sometimes 
ramified over the whole side of the face and head, 
and occasionally spreads much farther, so as even to 
implicate the shoulder and the arm. Neuralgia of 



COXSEQUEXCES OF CARIES. 69 

these, extending down to the hand, is often found to 
be instantly relieved by extraction of a diseased 
tooth; and any operator of much observation can 
call to mind numerous instances in which facial neu- 
ralgia has been thus relieved or wholly cured. This 
affection of the face, however, does not always origi- 
nate in diseased teeth, though there is little doubt 
that in a majority of cases it arises wholly or partially 
from this cause. 

Inflammation of the mucous membrane of the 
mouth is a common result of diseased teeth; and it is 
liable to extend to distant parts of this membrane, 
and occasion greater difficulty than in the mouth, as 
would especially be the case when there is an irri- 
table condition of the throat and bronchia ; and the 
esophagus and stomach are not exempt. In what 
degree such an implication of the respiratory and the 
digestive apparatus is referable to diseased teeth, it 
may not be easy to determine ; but it is impossible 
that a number of such teeth, involving in their 
disease all the ramifications of the facial nerves and 
the whole mucous membrane of the mouth, could 
remain there with impunity. And besides this direct 
influence on the lungs and stomach, diseased teeth 
are constantly emitting offensive odors, which are 
taken in by inhalation, and offensive matter, which 
is swallowed with the food. 



70 CARIES OF THE TEETH. 



TREATMENT OF CARIES. 

In the rational treatment of caries, the first con- 
siderations are the nature and peculiarities of the 
obvious predisposing causes ; whether these are con- 
stitutional or local; and if constitutional, whether 
they are such as can be modified by therapeutic 
treatment of the general system. If the latter, such 
treatment should be adopted as will bring about the 
most perfect state of health, so as to obviate as far as 
possible all conditions favorable to decay, by securing 
a healthy condition of the mouth in all its parts — as 
the gums, the mucous membrane, and the salivary 
glands. The teeth should be kept free from all 
deposits and accumulations of whatever character; 
for though some of these may not affect the teeth 
directly, yet they induce disease of the surrounding 
parts, and thus indirectly exert a pernicious influence 
upon them. 

The foregoing remarks, however, refer rather to 
the prevention of decay than to its treatment after it 
actually exists. Yet they are on that account none 
the less important, since here, as elsewhere, preven- 
tion is better than remedy. But they apply to such 
prevention as well after decay has commenced as 
before, if the ultimate object is preservation of the 



TREATMENT OF CARIES. 71 

teeth. After the first attack, the teeth are more 
vulnerable, and less capable of resistance. 

When decay has attacked a tooth, the treatment 
indicated depends upon the nature and extent of the 
disease. Rapid decay requires more prompt and 
energetic treatment than that of slow progress. 
Remedies appropriate and efficient in the one are 
quite inapplicable to the other. The persistence of 
caries is not always in proportion to its rate of 
progress. We sometimes find teeth in which the 
decay is not advancing rapidly, and thence are led to 
conclude that it may be easily arrested ; the affected 
part, if superficial, is easily removed, and the dentine 
thoroughly polished; and yet, after a time, decay 
again attacks the tooth at the same point. Or, where 
the caries has penetrated the tooth, so that it requires 
filling, though it is skillfully done, and the plug and 
tooth carefully polished, yet in many instances the 
dentine soon softens about the border of the filling. 

The extent and nature of the decay will suggest 
the mode of treatment. Superficial caries on some 
parts of the teeth may be remedied and removed by 
cutting away the portion implicated in the disease, 
dressing with a fine file, polishing with Arkansas, 
Scotch, or rotten stone till the file marks disappear, 
and then applying the buff with rouge or oxyd of 
tin very thoroughly to the entire surface operated 



72 CARIES OF THE TEETH. 

upon. Afterward, the most careful attention to 
cleanliness is requisite, to prevent a recurrence of 
the attack. This treatment is applicable to decay 
upon proximal surfaces ; but in the depressions of 
the masticatory and buccal surfaces of the molars, it 
is not practicable. 

Sometimes the dentine, at points where it is 
exposed, gives warning, by acute sensitiveness, of 
threatened decomposition, before there are any other 
indications of it, thus evidencing the presence of 
some very irritating agent promotive of decay. 
Such points should receive prompt and strict atten- 
tion, and the increased sensitiveness be immediately 
subdued ; as it may be by the use of some prepara- 
tion that Avill counteract the exciting influence — some 
dentifrice or lotion containing an alkali ; or rubbing 
the sensitive surface with a steel burnisher will in 
many cases effect this object, and prevent the 
development of decay. Nitrate of silver is some- 
times used for this purpose, and occasionally proves 
very efficient ; but its general use for such cases is 
of doubtful propriety, and when used, it should be 
with discrimination and caution. 

It has been suggested that the character of 
caries may be modified by the local application of 
therapeutic agents — that the rapid decay may be 
changed to the slow, and this, too, without regard 



TREATMENT OF CARIES. 73 

to the attendant circumstances, such as the condition 
of the secretions of the mouth, the causes producing 
the disease, etc. For this purpose various agents 
have been proposed. It is lield thai by an applica- 
tion of the nitrate of silver, the white, rapid decay 
being changed to that of a dark color, is arrested in 
its progress. But there is no very palpable principle 
on which this agent can be supposed to operate to 
arrest caries. It is generally conceded to be injurious 
to a healthy tooth ; how, then, it becomes beneficial 
to one decayed, it is not easy to perceive. The 
notion may have originated in the fact that after the 
application of nitrate of silver, the dentine to which 
it has been applied turns dark, or black; and this 
color being naturally associated with the slow form 
of decay, it may have been concluded that it might 
be thus associated by artificial means. This conclu- 
sioD, however, is fallacious ; for the coloring matter 
being the oxyd of silver, deposited on the walls of 
the cavity, is wholly foreign, and holds no necessary 
relation to the kind of decay, or to the agent pro- 
ducing it. The deposit may possibly serve as a 
temporary shield to the dentine beneath, but only 
temporary; whereas, on the other hand, it will be 
remembered that nitric acid is liberated by the 
decomposition of the nitrate, and operates destruc- 
tively upon the tooth-bone. An ethereal solution of 



74 CARIES OF THE TEETH. 

the terchloride of gold has also been suggested as a 
preventive application. Its operation would be much 
the same as that of the nitrate of silver, and equally 
inefficient. Preparations to neutralize and counteract 
the effects of deleterious agents upon the teeth have 
been recommended as topical applications. These 
are such as possess alkaline properties. But any- 
thing of this kind would require frequent application; 
indeed, it would be necessary to keep the affected 
part constantly under its influence, as long as the 
surrounding conditions continued to favor decay. 

Though nothing of this kind can be relied upon 
permanently to arrest caries, yet, in many instances, 
much benefit is to be derived from local treatment. 
Alkaline topical applications will in many cases 
alleviate the most acute sensitiveness of the dentine, 
accomplishing this, no doubt, by their neutralizing 
influence upon the irritating agents. Many opera- 
tors employ simply the bicarbonate of soda for this 
purpose, with the happiest results. As another class 
of topical applications to check or modify caries, 
those have been suggested which will form an insol- 
uble compound with the gelatinous or animal portion 
of the tooth ; such as tannin, creosote, and some of 
the essential oils. The only effect of these, however, 
is to form a shield or protection over the structure 
beneath : there is, of course, no change effected in 
the conditions or agents which produce decay. 



CHAPTER III. 

GENERAL REMARKS ON FILLINa. 

The importance and value of the operation of 
filling teeth are obvious, from various considerations. 
It is one that is in frequent requisition. It is the 
only treatment for deep-seated caries. By it the 
disease is arrested and the lost part restored, so far, 
at least, as it can be by a foreign substance. There 
is no material similar to that destroyed — no substance 
possessing the characteristics of the lost portion of 
the tooth, with which to effect the restoration. Under 
favorable circumstances, the operation of filling is 
efficient in arresting caries, and restoring, to a greater 
or less extent, the lost portion of the tooth. In 
order, however, that it be permanent in its character, 
the case needs to be attended with favorable condi- 
tions, and the work to be thoroughly done. But 
two similar operations, both equally well performed, 
may result very differently as to ultimate success in 
preserving the teeth to which they may have been 
apphed; the one effectually preventing further decay, 
and the other seeming to interpose to it but little 



76 GENERAL REMARKS ON FILLING. 

obstacle. Indeed, the probabilities of such success 
in different operations, equally well accomplished, 
cannot be calculated without considering a variety 
of circumstances, such as differences in constitutions, 
in states of health, in previous and subsequent habits. 

Filling teeth is predicated upon the nature of 
decay, upon the fact that the lost portion will not be 
restored by nature, and upon the fact that caries is 
an effect of external causes, and not of any cause 
within the tooth itself. If the causes of caries Avere 
alone within the tooth, then filling would not be its 
rational treatment. The organic structure of the 
teeth is of such nature" that no change to the extent 
of decomposition will take place in it independently 
of external influences. Any organ or structure sus- 
ceptible of becoming diseased by any cause resident 
within it, usually possesses the power of recupera- 
tion, and, in many instances, that of restoration also; 
and if dentine could be decomposed without external 
agents, the introduction of any foreign substance 
whatever into the cavity would certainly not arrest 
the decay, but most probably accelerate it. If it is 
true that decay of the teeth ever originates in con- 
stitutional causes alone, then the treatment should 
be constitutional, and not local. 

Filling teeth, then, is based upon the inability even 
of healthy dentine to prevent the occurrence of decay. 



GENERAL REMARKS ON FILLING. 77 

As preliminary to the operation, all the circumstances, 
both direct and collateral, should be carefully noted 
in every case, and the course of treatment should 
conform to the indications thus observed. The con- 
stitution, temperament, and health of the patient; 
the peculiarities of the teeth ; their susceptibility of 
decay ; their present condition, and that of the parts 
about them ; the periosteum, the gums, the mucous 
membrane, the secretions of the mouth, the saliva, 
and the mucus, should all be closely considered ; for 
only on a correct diagnosis can a proper treatment be 
based. Every operation should be performed as 
completely as, under the circumstances, it is possible. 
Indeed, every step in the operation should be perfect, 
before a succeeding one is attempted. All the instru- 
ments employed should be unexceptionable in mate- 
rial, form, and condition ; inferior instruments should 
find no place in the case of the dental operator. The 
material for filling should be of the best quality, and 
prepared in the best possible manner. Not that 
material for filling should be prepared in only one 
way ; for some materials, gold, for instance, may be 
prepared in three or four different forms, each perfect 
in its kind, and efficient in the hands of the expert 
manipulator. While with instruments and materials 
all in the most perfect condition, and with a thorough 
cognizance and appreciation of all the attendant cir- 



78 GENERAL REMARKS ON FILLING. 

cumstances, our most skillful operators barely attain 
success, need we be astonished that the man ignorant 
of all these circumstances, and possessed of only a 
few crude, ill-conditioned instruments and materials, 
the nature of which he does not understand, fails in 
almost every attempt ? 

Much depends on therapeutic treatment; not, in- 
deed, to restore parts already lost, or to restore to 
health parts much diseased, but to avert a tendency 
to disease in parts but feebly organized. This treat- 
ment may be either constitutional or local, or both ; 
but constitutional when there is indicated any idio- 
syncrasy favorable to decay. If, however, the whole 
difficulty is local, topical treatment only is required. 
What the special treatment should be in either case 
will be more fully considered hereafter. Compara- 
tively little can be accomplished by local application 
to the substance of the tooth ; but the parts contigu- 
ous, as the gums and the mucous membrane, may be 
thus treated, with an assurance of more signal results. 

Though in the teeth nature does not assist to re- 
store a lost portion, as in those parts more highly 
organized, yet, to compensate in some degree, the 
destructive process is far less rapid in the former than 
in the latter. The general surgeon depends much 
upon nature for the success of his operations ; for, 
though he performed them unskillfuUy, yet the kind 



MATERIALS FOR FILLING. 79 

energy of nature is always present to assist him ; 
but in this specialty the practitioner must necessarily 
depend more upon his skill, and less upon the cura- 
tive efforts of nature : though much more reliance is 
placed upon it now than formerly. 

MATERIALS FOR FILLING. 

In the selection of materials for filling teeth, there 
are some important considerations that should be 
kept constantly in view; the first and principal of 
which is to choose that kind which will protect the 
tooth from further decay — protect the afiected part 
against the influence of those agencies on which the 
disease depends. A material or class of materials 
should be selected that would not. under any cir- 
cumstances, induce either a local or a constitutional 
injury. 

There are several properties that materials for 
filling teeth should possess, one of the most import- 
ant of which is. 

IndesirudihUiti/. — Any substance, whether simple 
or compound, that will not maintain its identity and 
integrity when subjected to any conditions of the 
mouth, is wholly unfit to be used as a material for 
filling. If compounds are employed, they shouhl be 
such as would not be affected bv the secretions of the 



80 GENERAL REMARKS ON FILLING. 

mouth, or by any attendant conditions. A mere 
mechanical mixture would not be an appropriate 
material for permanent filling ; and all compounds of 
the metals, so far as we are familiar with them, are 
unfit for this purpose, by reason of the facility with 
which they are changed in the mouth. The next 
most important property of a material for filling is. 

Adaptability, — By which is meant a capability of 
being wrought into suitable shapes for the purpose, — 
a facility of being applied and conformed to the parts 
upon which it is to be placed. There are substances 
that would be entirely indestructible in the mouth, 
and that would be very desirable in other respects as 
materials for filling, that are yet altogether worth- 
less for this purpose, from lack of adaptability. 
Quartz, if it possessed this property, would be valu- 
able as a material ; but as yet there has been dis- 
covered no method of preparing it in an available 
form. On the other hand, many things possess the 
property of adaptability that are lacking in some 
other important particulars. The next important 
property is, 

Hardness. — A material may possess all the other 
suitable qualities, and yet be too soft. A material 
should be hard enough not to be broken or worn 
away by any pressure or friction liable to be applied. 
This property is especially desirable for fillings in the 



■ MATERIALS FOR FILLIXG. 81 

masticatory surfaces of the molars and bicuspids. 
It would, however, be admissible to employ a softer 
material for filling cavities in the proximal surfaces 
of the teeth, provided it would perfectly exclude all 
foreign substances. 

Non-conductor. — Again, a material should be as 
nearly as possible a non-conductor of heat, particularly 
for filling sensitive teeth, or those liable to become 
so under the influence of slight causes. Great varia- 
tions of temperature will in most instances aggravate 
sensitiveness, and, in susceptible cases, produce it ; 
and if the irritation is continued, the result may be 
necrosis. Gold, which possesses the largest number 
of desirable qualities as a material for filling, is in 
this respect very defective, being one of the best 
conductors of heat. To obviate this defect, some 
non-conducting material may be employed between 
the gold and the sensitive portion of the tooth. The 
pulp is liable to be affected by sudden and great 
changes of temperatui^e, transmitted to it through a 
gold plug. 

Cohesion. — In the next place, a material should be 
susceptible of being welded or united into a solid 
mass. The permanency of an operation depends very 
much upon this quality. A filling having the differ- 
ent pieces which compose it perfectly united, will be 
much more durable than if effected with a material 



82 GENEEAL REMARKS ON FILLING. 

in which this cohesive property is lacking, it can be 
made with greater facility, and will be better and 
longer retained; and mainly because such a filling 
cannot be destroyed piecemeal. Non-cohesive mate- 
rial is retained by the general form of the cavity, 
which is to be shaped so as to bind all the pieces 
together, and thus hold them in place ; but a sub- 
stance that will weld requires only two or three 
good retaining points, angles, or pits, properly 
situated, in order to be firmly and permanently fixed 
in a cavity of any form. 

Color. — Another desirable property of material for 
filling is such a color as shall best harmonize with 
that of the teeth, particularly if they are in front. In 
this respect all the metals are objectionable, though 
gold is probably less so than any of the others, the 
objection to this being not so much in its color as in 
its luster; which objection, however, may be partially 
obviated by the kind of finish given to the work. In 
teeth of certain shades — semi-transparent bluish- 
white, for instance — gold, for exposed fillings, is very 
objectionable, indeed, in some cases, almost as un- 
sightly as the absence of the tooth ; and in such 
instances, the darker metals would of course appear 
much worse. For such teeth, some mineral sub- 
stances, having more nearly the color of the teeth, 
would be the most desirable. 



MATERIALS FOR FILLING. 83 

Most of the materials employed for filling are metal- 
lic; only a few non-metallic substances have been 
used, and these rather by way of experiment, and for 
temporary purposes, than with any hope of permanent 
results. Of the metals, gold possesses more of the 
indispensable properties than any other ; but the fol- 
lowing have been used for filling • lead, tin, silver, 
platinum, gold, and amalgam. In the preparation 
of the latter, gold, silver, platinum, tin, bismuth, 
antimony, cadium, zinc, and mercury, have been 
employed. 

Lead. — This metal, in the early history of the 
profession, was used to some extent for filling teeth, 
though it possesses but few of the requisites for that 
purpose. The principal quality which recommended 
it is its adaptability ; but it is quite too soft for 
permanent fillings in the masticating surfaces of the 
molars. It is easily wrought into foil and welded 
into mass in the cavity, but it is rapidly worn down 
by mastication, and its integrity readily impaired 
by the influence of some conditions of the mouth ; 
much more readily, indeed, than that of tin or silver. 
Acetic and some other acids act upon it with con- 
siderable energy in the mouth. By exposure to air 
and moisture, it is soon coated with carbonate or 
protoxyd of lead ; and this change is effected much 
more readily in the mouth. Lead is also objection- 



84 GENEEAL REMARKS ON FILLING. 

able in color, especially for fillings in the anterior 
teeth, it being darker than the other metals employed 
for the purpose. It is, however, a less perfect con- 
ductor of heat than some others that are in far more 
extensive use. 

Tin. — This metal has been, and is even yet, much 
employed as a material for filling. It is easily 
wrought into foil, and in that condition is readily 
adapted to the purpose, by reason of its softness and 
pliability. Fillings can be made with it in all cases 
in which non-cohesive gold foil can be used, to much 
of which, indeed, it can by skillful manipulation be 
made superior in cohesive property. Its quality, 
however, is greatly dependent on the manner of its 
manufacture. It is harder than lead, and in many 
cases hard enough for permanent fillings ; it is fre- 
quently retained in crown cavities of the molars, 
effectually preserving the teeth for many years. In 
favorable conditions of the mouth, it is not materially 
changed, not oxydizing easily, and not readily uniting 
with any substances liable to be brought in contajst 
with it. But in an unhealthy mouth, with the secre- 
tions in an abnormal condition, and the teeth neg- 
lected, tin fillings are very rapidly destroyed by the 
action of nitric or hydrochloric acid. Such a change 
may take place in the mouth as will in a little time 
destroy tin fillings that had long remained in good 



MATERIAL? FO?. FILLING. 85 

preservation; and hence this material is not entirely 
reliable in any case, since such change may at any 
time occnr. Some cases seemingly favorable to its 
use are fonnd, on examination, to be otherwise; and 
in almost any month in which there is a large pro- 
portion of mucus secreted, it cannot be depended 
npon for permanency. Its color renders it unfit for 
the anterior teeth. It is a less perfect conductor of 
heat than gold, on which accoimt it is frequently 
employed where the latter metal can not be. It 
should not be used in a tooth in which there is 
another metal : notwithstandinsr some dentists do 
sometimes use it to fiU the interior of large cavities, 
placing upon it a covering of gold. This method is 
"objectionable in two particulars : first, the tin is 
softer than the gold, and under much pressure pelds 
beneath it. so as to destroy the integrity of the 
filling: and second, when the fltdds of the mouth 
come in contact with the two metals, a chemical 
action is induced, by which the tin is rapidly 
corroded. It is for this reason that no two metals 
should be applied to the same tooth: as. for instance, 
tin for filling a tooth round which there is a gold 
:lasp. or in contact with which is a gold plate. 
Finally, the use of this material should be deter- 
mined not only br all these circumstances, but also 
by the constitutional predisposition of the patient 



86 GENERAL REMARKS ON FILLING. 

and the character of the teeth, which should be 
dense and well organized, in order to render it at all 
admissible. It is frequently very valuable for filling 
the temporary teeth, and for temporary use in the 
permanent teeth. 

Silver. — This metal, in the form of foil, has never 
been used for filling teeth except experimentally. 
It is not for this purpose superior to tin in any 
particular, except in being somewhat harder; and in 
some particulars it is inferior, being quite as destruc- 
tible in the mouth ; more easily affected by certain 
agents, such as nitric acid, nascent chlorine, etc. ; 
less pliable and less adaptable ; more difiicult to work 
into foil; not so readily formed into fillings; and 
possessed of much less cohesiveness, being almost 
unweldable by the ordinary method of manipulation. 
Silver is a better conductor than tin, and would 
therefore in many cases be more objectionable. The 
saliva is often in such a condition as to act upon it 
with rapidity. Its color, too, is objectionable. Having 
these disadvantages, its use has very properly never 
been adopted. 

Platinum, — This metal has been but little used for 
the purpose of filling, though it possesses some of 
the requisite qualities in a very high degree ; as, for 
instance, indestructibility, in which property it is 
superior to gold. In other respects, however, it is 



MATERIALS FOR FILLING. 87 

very deficient ; it has not as yet been wrought into 
any form in which it can be welded with facility; it is 
difficult to work into foil, and when it is put into this 
form, it possesses a stiffness and harshness that ren- 
der its adaptation and condensation almost impracti- 
cable. It is more on this account, perhaps, than on 
any other, that it has been so little employed for the 
purpose of filling. It has also less cohesiveness than 
gold, and much sooner parts wdth this property. Slight 
crumpling or bending serves to stiffen it, so as to 
destroy its applicability. Good fillings may be made 
of well-prepared platinum sponge, recently annealed. 
It requires skillful manipulation, however, for the 
least moisture destroys its cohesive property entirely. 
It is a good conductor of heat, and on this account 
objectionable. In the respect of color, too, it is unde- 
sirable. Platinum should never be placed in close 
proximity to tin fillings, or to gold plate or clasps of 
low carat. It is, however, being employed to some 
extent in connection with gold, which in some respects 
seems to serve a valuable purpose. It is used in the 
form of foil, of any desired thickness, heavily coated 
with pure gold. The claims for this combination 
are, that a far harder and more resistant filling can 
be made than with gold alone, and a modification of 
the color of the gold that is far preferable for teeth 
of certain shades of color. 



88 GENERAL REMARKS ON FILLING. 

Gold. — ^Of all the metals that have as yet been 
used for filling teeth, gold possesses more of the 
requisite properties than any other, and sufficiently 
so for all practical purposes. Twenty-carat gold is 
very seldom affected by any agencies with which it 
is brought in contact in the mouth ; pure gold never. 
In the filling of teeth, there are two objects to be 
aimed at : one, a sufficient hardness to withstand the 
wear of mastication ; the other, a thorough protection 
to the cavity against all decay-producing agents. For 
the attainment of the first of these, gold is not all 
that could be desired ; yet it is, perhaps, as efficient 
in this respect as any other metal that can be em- 
ployed. But the second object, gold, when well 
manipulated, accomplishes very effectually : that is, 
so long as the filling maintains its integrity ; after it 
is partially worn out, it thus far fails, of course. In 
adaptability, too, gold is superior to any other metal. 
It can be wrought into a variety of forms, with any 
of which very good fillings can be made. It can be 
perfectly conformed to any shape of surface, however 
irregular. A tooth that can be filled at all, can be 
filled with gold. This assertion was made a number 
of years ago ; and if it was true then, it is much 
more true now; for then the cohesive property of 
gold was not employed at all, or even recognized as 
available ; but now, this property has been rendered 



I 



MATERIALS FOR FILLING. 89 

efficient and practicable. Then, our best operators 
did not aim to unite the different portions of gold of 
which the fillings were composed. The idea that 
such consolidation could be effected seemed never to 
have entered the mind of any one. Indeed, with the 
instruments and the method of manipulation then 
employed, this cohesive property could not have been 
made available ; but as it came' to be recognized, the 
instruments and the manipulations were adapted to 
the purpose. Formerly, an ordinary gold plug when 
removed from a cavity could be readily separated 
into as many pieces as originally composed it ; but 
now, when cohesive gold is skillfully used, the mass 
composing a filling can not be divided into its original 
parts, but may be wrought into plate, wire, or foil. 
Non-cohesive gold — the modification in which, till 
about the year 1859, it was always employed — would 
not weld, even under great pressure ; but in the mode 
in which it is now prepared, it will weld readily and 
thoroughly. There are certain requisites essential to 
this welding property of gold. If it is in the form of 
foil, it should not present a smooth, planished surface ; 
it must be annealed after hammering, in order that 
its ultimate particles may be in the best condition for 
cohering ; it must be entirely free from all deposits 
of foreign substances ; and it must be kept from ex- 
posure to the atmosphere. 



90 GENERAL REMARKS ON FILLING. 

Grold is a good conductor of heat ; and this is the 
chief objection to it as a material for filling. As to 
sensitive teeth, this is a very serious objection, in 
some cases necessitating the employment of non- 
conducting material beneath it, and in others preclud- 
ing its use altogether. The color of gold, however, 
is seldom an objection to its use, though it sometimes 
renders it unsuitable for fillings in the front teeth. 
But this objection has been already adverted to. 

Various Preparations of Gold. — And first, of the 
manufacture of gold foil. For this purpose pure 
gold is used, for procuring which various methods 
are employed. But the most common of these are 
insufficient for the production of gold absolutely pure. 
It is, however, deemed irrelevant here to detail the 
process by which this end is attained : it is enough to 
premise that, for the manufacture of the best quality 
of foil, pure gold is indispensable. The gold is cast 
into an ingot about an inch wide, is then placed 
between a pair of rollers^ and milled down as thin as 
practicable, the piece, while in this process, being 
frequently annealed. It is then cut into squares, 
which are inserted with wooden pliers between vel- 
lum leaves, a hundred and sixty or seventy in a 
pack. Over this pack two pockets are drawn, inclos- 
ing it completely. The pack is then hammered on a 
granite block, with a hammer weighing twelve or 



MATERIALS FOR FILLING. 91 

sixteen pounds, till the leaves are spread out to the 
full extent of the pack. They are then removed 
from the pack, cut into four sections, annealed, re- 
placed in the pack, and again subjected to the ham- 
mer ; this process is repeated till the desired thick- 
ness of foil is obtained. Much experience and skill 
are requisite to the proper accomplishment of this 
part of the work. By a single unskillful stroke of 
the hammer, a whole pack may be spoiled. 

Gold foil is numbered according to the grains con- 
tained in each leaf, ranging from 2 to 240. The most 
common numbers are, 2, 4, 6, 10, 20, 30, 60, 120, and 
240 — the latter seldom used; of the smaller num- 
bers, 4 and 6 are in most frequent use. It has 
heretofore been a desideratum to obtain gold foil per- 
fectly uniform in quality. This seems now to be 
almost if not altogether attained by the most careful 
and skillful manufacturers. 

Crifdal Gold, — This form of gold was introduced 
to the profession about twenty-two years ago. Some 
experiments in this direction, indeed, had been made 
as early as 1825, by C. Ash, of London, and again in 
1850, by Dr. S. A. Main, of New York. Their pre- 
parations, however, were simply precipitates, and 
nothing more. But in 1853, Dr. A. J. Watts, of 
Utica, New York, obtained letters patent for this pre- 
paration of gold for filling teeth. This preparation 



92 GENERAL REMARKS ON FILLING. 

was at first denominated sponge gold, but after some 
modification, received its present name. There are 
numerous formulas by which preparations of crystal 
gold may be made ; but so far as we are acquainted 
with them, they are all embraced in two general 
methods : the one, to obtain simply a precipitate of 
the metal adaptable to the filling of teeth ; and the 
other, to combine this precipitate with mercury, 
and obtain a definite crystallization. For the prepa- 
ration of the sponge or crystal gold, the absolutely 
pure metal is required. This is dissolved in nitro- 
muriatic acid, the gold being added till the solution 
is saturated. Various materials may be used to pre- 
cipitate it, the most common of which are sulphate of 
iron and oxalic acid, the latter on some accounts 
being preferable. The character of the precipitate " 
will be determined, in a great degree, by the manner 
in which the precipitant is added : if slowly, the pre- 
cipitate will take a more definite form, inclining to 
the crystalline or fibrous. 

A preparation may be made by introducing the 
precipitant gradually, and then carefully washing the 
precipitate, and heating almost to redness. For per- 
fect crystallization of the gold, combine the precipi- 
tate with from six to twelve times its weight of pure 
mercury ; let it stand a short time, subject to a gentle 
hea,t, and then remove the mercury with dilute nitric 



MATERIALS FOR FILLING. 93 

acid. Afterward wash the nitrate of mercury from 
the gold ; place the latter upon a slide, and bring it 
up to a full red heat in a muffle, and the gold is 
then in a condition to be used for filling. This is 
about the formula on which a patent was granted to 
A. J. Watts. The preparation possesses some advan- 
tages over gold foil. It is as readily introduced ; it 
is more capable of thorough consolidation ; it has, 
besides the cohesiveness of foil, the additional prop-* 
erty of interlacing its crystals one with another, by 
which property, even without cohesion, the pieces of 
a filling can be firmly united ; and it takes a better 
hold upon the walls of the cavity, to Avhich it 
presents the angles and ends of the crystals, so as 
to be more thoroughly adapted and fastened. 

Amalgam. — By this term are designated all those 
preparations formed by a combination of mercury 
with various other metals ; most frequently with sil- 
^'er and tin, but occasionally with gold, platinum, 
bismuth, cadmium, zinc, and lead. The several for- 
mulas for amalgam need not here be specified. The 
kind most in use is prepared by melting together and 
carefully mixing pure tin and silver, filing this mix- 
ture, when cooled, into dust, combining the latter 
with mercury in sufficient proportion to give the 
requisite plasticity, and then thoroughly washing the 
whole in alcohol or boilino: water, to remove the 



94 GENERAL REMARKS ON FILLING. 

oxyds formed during the combination of the metals. 
If there is a redundance of mercury, it may be 
removed by pressing the paste in a piece of chamois 
skin. This preparation may in some cases be used 
for filling with considerable success ; but in no case 
can it be relied upon as a durable material, its 
destructibility being no less than that of tin or silver 
in any circumstances, and being greater where all the 
excess of mercury is not removed from the surface of 
the filling, and the surface not burnished down solid 
and smooth. Mercury oxydates with considerable 
rapidity when exposed to air and moisture, and with 
increased energy under the influence of heat, espe- 
cially when some acid is present. This facility of 
oxydation is still increased when other metals are 
combined with mercury. Oxydation of such fillings 
will in some cases be confined to the surface, wher- 
ever there is contact of moisture ; in others, it will 
pervade the whole mass, rendering it black and 
spongy throughout. 

Amalgam fillings, in a short time after their inser- 
tion, undergo a hardening process, occasioned by 
crystallization of the mass, as well as by evaporation 
of the mercury. The consequence is, either that the 
mass becomes porous, or that it contracts ; the former, 
doubtless, in cases where the oxydation extends 
through, and the latter where it is confined to the 



MATERIALS FOR FILLING. 95 

surface. When a plug is in either of these condi- 
tions, the preservation of a tooth is very uncertain. 
On removing an ordinary amalgam plug that has 
been worn for some time, its entire surface will 
generally be found oxydized ; and a tooth filled with 
this material generally becomes blackened, and its 
appearance ruined. 

To such objections against this material, another is 
to be added in cases in which there are fillings or 
plate of platinum or gold : galvanic action will be 
established, in a degree proportionate to the proxi- 
mity and extent of surface of the metals and the 
condition of the secretions. This may occasion much 
mischief. Some constitutions are very susceptible of 
the influence of mercury ; and a gradual decomposi- 
tion of several amalgam fillings in the mouth may 
seriously impair the general health. Therefore, before 
this material is ever employed, the health, tempera- 
ment and habits of the patient should be carefully 
noted ; for these and other circumstances may often 
indicate its inadmissibility. 

So great and so numerous are the objections to 
this material, that it is wholly discarded by some in 
the profession, and but sparingly used by a great 
many others. Its adaptability is the main property 
on which are based the arguments in its fiivor. It is 
easily applied, and becomes very hard upon crystal- 



96 GENERAL REMARKS ON FILLING, 

lizing. It is affirmed, also, that teeth which cannot 
be saved with anything else may be filled with this, 
and made valuable. This, however, is not true since 
the employment of the cohesive property of gold, 
which quality renders this metal equal in adaptability 
to amalgam. 

Oxy-cliloride of Zinc. — This preparation is of a 
semi-metallic character; it consists of oxyd of zinc 
and chloride of zinc in combination, and hence is 
commonly denominated oxy-cMoride of zinc. 

Os Ajiifcicd is a conventional name of rather 
doubtful propriety. This preparation has been for 
quite a number of years in very general use; 
and when well prepared, and properly manipulated, 
serves a very valuable purpose. In some cases it 
resists the secretions of the mouth quite effectually. 
For proximal fillings it resists the wear of mastica- 
tion well, but for crown fillings it is not sufficiently 
resistant. It is one of the best materials for tempo- 
rary fillings. A little experience renders its use easy. 
It effectually excludes all foreign substances, is a 
good non-conductor, and is only displaced by wear 
and the solvent power of the saliva in some vitiated 
conditions. Guilloi's Cement, and Cement Plomb are 
preparations in all practical aspects similar to oxy- 
chloride of zinc. Some variation in the method of 
manipulating them is required. There is found some 



MATERIALS FOR FILLING. 97 

difference of susceptibility in these different prepara- 
tions to the vitiated secretions of the mouth. It 
is a good protection to sensitive dentine, and in 
many cases for exposed pulp, under gold filling. It 
more nearly resembles the natural teeth in color than 
any other material that has been used for filling. 

Non-metalUc Materials, — Of the non-metallic mate- 
rials employed for filling teeth, there are not many 
worthy of any particular consideration. Indeed, 
gutta-percha and its preparations constitute the chief 
of these substances now used for this purpose, though 
some others have been employed. Gutta-percha is 
useful for temporary fillings, and, under ordinary cir- 
cumstances, is suflQciently durable. It is valuable 
for filling those teeth which it may be desirable to 
retain only a short time, or those in which it may be 
necessary temporarily to protect a sensitive part 
against the influence of irritating agents, in order to 
restore it to health. Gutta-percha is not readily 
decomposed by the fluids of the mouth, when they 
are in a healthv condition. In some instances we 
have known it worn in the mouth for years with but 
little change. But in cavities on the grinding sur- 
faces of the molars and bicuspids, it will not with- 
stand the wear of mastication a great while, though 
long enough in most cases to subserve the purposes 
of temporary fillings. It possesses great adapta- 



98 GENERAL REMARKS ON FILLING. 

bility. By simply being warmed over a spirit-lamp 
or in boiling water, it becomes plastic, and is with 
great facility introduced and conformed to the cavity. 
It may be applied also in solution, being dissolved in 
chloroform till it approaches a pasty consistence, then 
absorbed in a pledget of cotton, and introduced into 
the cavity, where the chloroform evaporating, leaves 
the gutta-percha as a filling. The only objection to 
this method is the contraction consequent on the 
evaporation of the chloroform. Another property 
that renders this substance highly valuable, is its 
non-conduction of heat, it being in this respect as 
nearly perfect as any other material employed. 

A preparation of gutta-percha with mineral sub- 
stances, known as HilVs stopping , has for some years 
been extensively used for temporary fillings ; indeed, 
it has superseded simple gutta-percha almost entirely. 
The aim of this preparation was to obviate two or 
three objections to pure gutta-percha; as, its contrac- 
tibility in the cavity, its softness and its color. The 
composition of HilVs stopping is as follows : With 
pure gutta-percha in a plastic state are mixed quick- 
lime two parts, and quartz and feldspar one part 
each, which latter are reduced to an impalpable 
powder, and kneaded into the mass as long as it will 
receive them without becoming brittle. Such is the 
formula given by the inventor of this preparation ; 



MATERIALS FOR FILLING. 99 

though it is presumed that one of these materials 
alone, namely, pulverized quartz, would be found 
entirely sufficient, since it is capable, by itself, of 
quite as much as is attained by all together. The 
addition of gold or platinum fillings has been recom- 
mended ; but no advantage is thus gained. It was 
at first claimed for this material that it would serve 
for permanent fillings ; but it was soon demonstrated 
to be insufficient. It was supposed, also, that it 
might be employed for partial fillings in large cavities, 
which could be completed with gold ; but for this, 
too, it was found impracticable, since it did not make 
a sufficiently firm foundation. 

This preparation is applied in the same manner as 
simple gutta-percha, being warmed on a porcelain or 
metal slab over a spirit-lamp till sufficiently soft, and 
then packed into the cavity. It cannot be employed 
in the form of solution, nor should it be softened in 
boiling water. It may be conveniently prepared by 
dissolving the gutta-percha in chloroform to almost 
a pasty consistence, then adding the mineral sub- 
stances, and putting it into a vessel suitable for the 
evaporation of the chloroform. It should be made so 
thick that the silex would not fall to the bottom. 
When HilVs stopping or gutta-percha is used, as soon 
as the cavity is filled, an instrument with the end 
nearly as large as the orifice of the cavity, should be 



100 GENERAL REMARKS ON FILLING. 

placed upon the filling, and retained there with con- 
siderable pressure till the mass is cool. After cutting 
and dressing the surface of the filling as thoroughly as 
can be with instruments, then by passing over the 
surface a short camel's-hair brush, with chloroform, a 
very smooth surface and perfect finish will be made. 
In some respects, there is perhaps nothing better 
for temporary fillings than this preparation of gutta- 
percha. 



CHAPTER IV. 

INSTRUMENTS FOR FILLING. 

In describing the instruments for filling teeth, it 
will be convenient to take them somewhat in the 
order in which they are employed in ordinary prac- 
tice ; first referring to those which are used for cut- 
ting away portions of the teeth, for the purpose of 
separating them, and for dressing off the borders of 
cavities ; then to those for removing decay and form- 
ing the cavities ; and finally to those for introducing, 
consolidating, and finishing fillings. The first, then, 
that claim our attention, are the 

HEAVY CUTTING-INSTRUMENTS. 

These are of the thick chisel-shape. They should 
be of good steel, well wrought, and thoroughly tem- 
pered. Every step in the process of their manufac- 
ture should be most perfectly executed, so as to 
insure an edge that will cut not only dentine, but 
also enamel, which is the hardest animal substance. 
Various sizes of the straight chisel-form are required. 

In all cases they should be as thick as possible, with- 
out being thus impaired in their efficiency ; so firm 



102 



INSTRUMENTS FOR FILLING. 



that there may be no springing or tremulous motion 
under the pressure they are required to sustain. For 
separating front teeth, however, they must be thin 
enough to pass readily into the intended space, and 

Fig. 3. 



about one-fourth of an inch wide at the edge. But 
for separating bicuspids and molars, the instruments 
should be thicker and broader ; as thick, indeed, as 

Fig. 4. 




the required space wdll admit. In some cases they 
should have the edge oblique, as in Fig. 5. 

It is seldom that these instruments need any curve. 
Fig. 5. 




The straight form is the best, unless, as rarely hap- 
pens, the point to be operated upon cannot be reached 
efficiently with it ; as, for instance, in a small mouth, 
a slight anterior curve will be required in the shaft 
of the instrument, to facilitate its approach to the 
front proximal surface of a second or a third molar. 



HEAVY CUTTIXG-INSTRUMENTS. 



103 



Fig. 6, a heavy instrument, with a sharp point 
and a lateral c-nrve, is often efficient in opening up 



Fio;. 6. 




cavities and cutting down strong projections of 
enamel. Fig. 7 we consider as a very valuable 
form. Every operator should have at hand a suffi- 




cient variety to meet every demand — from three to 
five sizes of each form. 

These instruments are now made with steel han- 
dles, much smaller than those represented above, and 
are used with the mallet. 

The following (Fig. 8) will give an idea of the 
variety of sizes that are desirable : 



\f\f\r 



i 1 1 



\r 



\ r 



W M 



I 



< I I 



104 



INSTRUMENTS FOR FILLING. 



DRILLS. 

Bur Drills. — Of this indispensable class of instru- 
ments there are various forms. They should be manu- 
factured of the best steel, and wrought with the 
greatest care. After having been forged as near the 
proper size as possible, the bulb is shaped by dressing 
with a fine file, or, which is better, by turning in a 
lathe, those made by the latter method being supe- 
rior, and cutting much more smoothly ; they do not 
catch and jar as do those of less regular form. After 
the bulb is formed, it is cut with a sharp-edged file. 

Fig. 9. 



Of these drills, Fig. 9 represents a bur of a spher- 
ical form. Fig. 10 is cone-shaped, which may have 

Fig. 10. 



various degrees of bevel, terminating in a sharp point. 
Fig. 11 is of a cylindrical form, cut upon the sides 

Fig. 11. 




and end. Fig. 12 is in the form of a wheel, cut upon 



DRILLS. 105 

the edge only, or upon both the edge and the end. 
The cutting upon ail of these should be very regular 
and uniform. This should be made by machinery, 
though it is usually done by hand. Of these instru- 

Fiff. 12. 



ments, there should be a variety in size, the smallest 
considerably less than the smallest cavity the dentist 
ever attempts to fill — that is about one thirty-second 
of an inch in diameter, and the largest about one- 
fifth of an inch. Inclusive of these extremes, there 
should be about ten sizes of each particular form. 
These instruments are used for opening cavities. 
With them a more regular and perfect orifice is made 
in small and medium-sized cavities than by any other 
method. They are also used to some extent for 
forming the cavities, and even sometimes, in large 
cavities, for making retaining-points for a filling. 

Some years ago, Dr. Scranton devised a rather 
peculiar kind of drill, and efficient withal. Its form 
is spherical, and in its manufacture the bulb is made 
as for the ordinary bur drill ; but instead of having 
cut upon it numerous serrations, thus forming a 
series of sharp edges, a concave cut is made upon 
two opposite sides with a small round file. The 
instrument then presents two concave and two convex 



106 INSTRUMENTS FOR FILLING. 

sideSj with four sharp longitudinal edges ; these may 
be so inclined as to cut only when rotated in one 
direction, or to operate alike well when rotated 
either to the right or the left. 

This instrument has two or three advantages over 
the ordinary bur ; it can be kept sharp with the oil 
stone till it is almost entirely used up, and will con- 
sequently last much longer; and it will cut much 
more rapidly than the serrated bur. It is a very 
valuable instrument for operating upon firm, strong 
teeth. It is represented in Fig. 13. 

Fig. 13. 

Z 
— ,— ...^ ® 



Common Brills. — Of other drills, Fig. 14 repre- 
sents one with a square point, beveled from both 

Fig. 14. 



sides, measuring from a half to a whole line in 
width, and attached to a small round shaft. The 
edges of the drills should be very hard, so that they 
may cut with the greatest celerity. Of this kind 
there should be about ten sizes, ranging in width 
from No. 12 to No. 25 of Stubb's gauge. These 



DRILLS. 



107 



are used mainly for forming retaining-points in 
cavities. 

Fig. 15 is the spear-shaped drill, the edges of 
which are formed by dressing from both sides ; or, 



Fiff. 15. 




it may be, from only one, in which case it will cut 
only when rotating one way. This shape is employed 
principally for drilling out roots for filling, or receiv- 
ing pivot teeth. 

The burs and drills may be made of pieces of wire 
one inch and a half long, and fitted to a socket- 
handle that will accommodate a large number ; or of 
a continuous piece of large wire. The latter is the 
preferable method, since much time is consumed in 
changing them in sockets. The handles should be 
made with six or eight sides, and cut on each alter- 
nate side. In the use of these instruments, the 
driU-ring is almost indispensable. This is a ring 
used on the middle or the index finger, with a 
socket attached, in which rests the end of the handle 
of the instrument. (Fig. 16.) The drill is rotated 
commonly with the thumb and fingers. 



108 INSTRUMENTS FOR FILLING. 

Fig. 16. 




Drill-stocks of various forms have been invented, 
with the view of increasing the motion of the drill, 
of augmenting its power, and especially of bringing 
it to bear upon points inaccessible to the straight 
instrument. 

The use of the burs and drills by the hand, and 
by means of the various drill-stocks, has been almost 
wholly superseded by the introduction and use of 
the dental engine. 

This appliance, in a far less perfect form than now, 
was introduced to the dental profession about the 
year 1870. 

Mr. Green, of Michigan, first introduced the pneu- 
matic engine; succeeding this, was that denominated 
The "Morrison Engine." Within a short time after 
this, the suspension engine was devised and con- 
structed by Dr. W. S. Elliott. 



109 




110 INSTRUMENTS FOR FILLING. 

This engine possesses some excellent qualities. 
Its steadiness of motion, freedom from tremor or 
backlash, and the facility of use, are qualities that 
make it very valuable in these respects. When the 
large dressing burs or polishing cones are being used, 
it is superior to any other. 

The illustration on page 109 (Fig. 17) gives a cor- 
rect idea of the machine. 

Various other modifications of dental engines have 
from time to time been presented, a description of 
which is unnecessary here. That improved by, and 
bearing the name of, S. S. White, is at present very 
popular; it has now the most prominent position 
before the profession ; other modifications, however, 
are highly esteemed by many. It is well represented 
by the illustration on page 111 (Fig. 18). 

This engine certainly posesses many desirable 
qualities. The facility of movement and adapta- 
tion afforded by the flexible cable, and the hand- 
piece, seem to be about all that can be desired. 
The mode of attachment to and retention of the 
drills and other accessories by the hand-piece, 
leaves little or nothing more to be desired in that 
direction. 

Attachments are made to the hand-piece by which 
drills are operated at a right angle with the shaft, 
and also at an acute angle, or with a backward incli- 



DRILLS. 



Ill 



Fig. 18. 




112 



INSTRUMENTS FOR FILLING. 



nation to almost forty-five degrees. They are shown 
in Fig. 19. 

Fig. 19. 




Some description and illustration of the instru- 
ments and appliances used with the engine might 
appropriately be given here ; but so numerous have 
they become that it is impracticable to give more 
than a representation of each class. 

Fig. 20. 




Fig. 20 presents illustrations of the spherical and 
wheel burs, three sizes. Of each class of burs there 
should be eight or ten sizes ; it would also be well 
to have two or three grades, as respects fineness of 
cut : the coarser will serve for rapid work, and the 
finer for the smooth and more perfect work. 



DRILLS. 



113 



This variation may with propriety pertain to all 
forms of burs used upon the teeth, and those used 
for dressing fillings as well. 

Fig. 21 shows the cone and the inverted cone- 
shaped burs ; about the same variety in number and 
size will be required as of the spherical. 

Fig. 21. 




In Fig. 22 are presented the fissure burs, square 
and pointed. 



Fis. 22. 



In Fig. 23 are shown the bud-shaped and oval 
burs. 



Fio;. 23. 




114 



INSTRUMENTS FOR FILLING. 



In the following illustration are shown the 
flexible burs and drills for operations in canals of 
roots. 

Fig. 24. 




Fig. 25 shows the spear, the square edge, and the 
spade-shaped drills, all flat, and the twisted drill. 



Fig. 25. 





n 



The burs and drills here presented embrace all 
the principles that have been employed in the ordi- 
nary operations upon the natural teeth. 

Of the plug-dressing burs a large variety is made ; 
nearly the same general forms have been adopted 
as in those for operating in cavities of decay. 



DRILLS. 



115 



The following illustration gives the most common 
forms. 

Ficr. 26. 





In the following is shown a set of burnishers 
for finishing fillings. 

Ficr. 27. 




The following illustrates a set of corundum points. 



cones and disks for finishing fillings. 



Fig. 2b. 




About the same forms and sizes of points for 
finishing are made of Arkansas, Scotch, and Hin- 
dostan stones. These are all valuable, and should 



116 



INSTKUMENTS FOK FILLING. 



always be at hand, and a sufficient variety of sizes 
to meet all cases. They are shown by Fig. 29. 

Fig. 29. 




EXCAVATORS. 

Of the small cutting-instruments for opening and 
forming cavities, and removing decay from them, 
there is a great variety, though a few general forms 
comprise the v/hole. Until within comparatively a 
short time, there has been no very systematic arrange- 
ment of these instruments, such as the convenience 
both of the profession and the manufacturers of 
dental instruments would seem to dictate. In a 
classification that we have adopted and found very 
convenient, they are arranged by numbers, the most 
simple being placed under the first, and under each 
successive number a more complicated form. All 
the varieties are embraced in twelve numbers, 
which are represented in Fig. 30. These varieties 
are discriminated by the forms of the points, and 
their position on the shaft to which they are attached, 
and not by any curve which the shaft may have at 
any distance from the point. 



EXCAVATORS. 



No. 1 has simply a flat point slightly curved, 
Avith a round edge transyerse to the shaft. Four 
sizes will be sufficient for ordinary purposes. 



Fig. 30. 




No. 2 has a flat point with a short curve, bring- 
ing the point to a right angle with the shaft; the 
edo:e is transverse. This differs from No. 1 in 
having the curve more short and abrupt, and the 
edge more nearly square. Of these there should 
be five sizes, with some variety of form. 



118 INSTRUMENTS FOR FILLING. 

No. 3 has a flat point with a square transverse edge, 
which rises at a right angle from the shaft ; the blade 
being from one to two lines in length. Five sizes. 

No. 4 has a flat point, curved so as to be at a 
right angle with the shaft; the blade, from the 
centre of the curve to the edge, being from one and a 
half to three lines, and the edge straight. Four sizes. 

In each of the foregoing the edges should expand 
slightly in width. 

No. 5 has a flat point with a square edge, which 
is parallel with the shaft, and rises at a right angle 
from it. The blade is from one-half to two and a half 
lines in length, and from one-half to one line in width, 
with no expansion at the edge. . Six sizes, with 
some variety of form. 

Nos. 6 and 7 are right and left excavators, with 
flat points and double curves; the first curve being 
at an angle of about twenty degrees, and the other 
lateral, right and left, reaching from the beginning 
of the' first curve to the point. The length of blade 
is from one to three lines. Four sizes. 

No. 8 has a crescent-shaped point, the blade 
rising by a small attachment from the shaft, and 
making a right angle with it. The edge is a regular 
curve, describing about two-fifths of a circle, and 
is parallel with the handle. The point should be 
perfectly formed. Six sizes. 



EXCAVATORS. 119 

No. 9. The form of the point is the same as in 
No. 8, the difference being in the position of the 
blade, the edge of which is transverse to the shaft, 
and rises from it at an angle of one hundred and 
thirty degrees. Six sizes. 

In No. 10 the point has the same shape as in 
Nos. 8 and 9. The cutting edge is transverse to 
the shaft, and rises by a small neck at a right angle 
from it. Six sizes. 

Such are the most important forms of excavators, 
though modifications will be required for particular 
cases. While Nos. 8, 9, and 10 are not in exten- 
sive use, a few operators have used them for some 
years, and prize, them very highly. In many diffi- 
cult cases they are far more applicable than any 
other instrument we have. For instance, in the 
formation of the cervical wall of a proximal cavity 
in any of the teeth, but particularly in the superior 
bicuspids and molars, there is no other instrument 
so applicable and efficient as No. 9 ; with it, that 
part of the cavity, so frequently neglected, is just 
as easily formed as any other. 

Cases will occasionally be presented in which 
some curvature of the shaft of the instrument will 
be requisite. But no more curve should be given 
to any instrument than may be absolutely neces- 
sary, for it is impossible to manipulate with the 



120 INSTRUMENTS EOR FILLING. 

same precision and delicacy with curved as with 
straight instruments. The degree of curve neces- 
sary in any given case will be determined by the 
position of the decay on the tooth, and the location 
of the latter in the mouth. 

The diamond point, as it is familiarly called, is 
a modification of No. 3, varying from it in that it 
has a sharp point instead of a square edge, and is 
three-sided from shaft to point, each angle being 
a cutting edge. This instrument is especially valu- 
able for forming grooves or furrows within cavities, 
and for dressing the borders. 

After being much reduced by use, it may still be 
kept in form, and sharp, and used as a drill for 
making under-cuttings, for which it is very efficient. 
No. 11 represents this instrument. 

A modification of No. 9, commonly known as 
the scoop or spoon-shaped instrument, is extensively 
used. The sharp corners of No. 9 are removed 
in this instrument. It is shown in No. 12. 

Since the issue of the second edition of this work, 
efforts have been made by several members of the 
profession to arrange and systematize excavators 
into sets, that should embrace every desirable form 
and size. No one has as yet succeeded in pro- 
ducing that which meets the views of all operators. 

There is, perhaps, now more diversity of opinion 



EXCAVATORS. 



121 



and practice in reference to the use of hand ex- 
cavators, in the preparation of teeth for filling, than 
ever before, from the fact that a great diversity of 
practice exists in reference to the use of the dental 
engine and its accessories for this purpose; some 
using these almost exclusively in the preparation 
of cavities; others for this purpose making far less 
use of the engine, and more use of the hand ex- 
cavators, claiming that with the latter much more 
precise and definite execution can be attained. 

Fig. 31 presents an arrangement of excavators by 

Fig. 31. 

fl J 8 8 [j a 5 1 f ^ 



Dr. I. J. Wetherbee, very good indeed so far as they 
extend, and perhaps in the majority of cases they 
would quite suffice. 

Of the Manufacture of Excavators. — For making 
these instruments, the best cast-steel wire. No. 8, 
should be selected. This should be foro:ed down 



122 INSTRUMENTS FOR FILLING. 

SO as to leave the end large enough to form the 
intended point. Nos. 1 to 6 inclusive, Fig. 30, 
may be formed by forging, and afterward dressing 
up with the file. Nos. 8 to 12 inclusive should 
be formed by the files out of a bulb left from the 
forge ; for this purpose different forms and sizes of 
files will be required, in order definitely to shape all 
the angles and points. In heating steel, either for 
forging or tempering, a full red heat should in no 
case be exceeded, since a higher degree than this 
spoils it. After the points are formed, and made 
smooth with an emery stick or wheel, they are to 
be tempered ; this is a delicate process, requiring 
much experience and care. The point should be 
warmed in a spirit-lamp, and then covered with 
soap, to prevent oxydation and scaling. The in- 
strument is then brought up to a full red heat 
with a spirit-lamp, blow-pipe, and charcoal, and 
suddenly plunged into a cake of soap or into cold 
water, when it will present a silvery whiteness ; 
the steel in this condition is extremely hard and 
friable. It should then be polished off with an 
emery stick or oil-stone, and drawn down to the 
proper temper. This tempering is accomplished 
by placing the edge of the instrument on a piece 
of cold polished steel or iron, and its shaft placed 
near or in the flame of a small spirit-lamp, and 



EXCAVATORS. 123 

retaining it there till it changes to a deep blue 
color, graduated down to the point in a deep straw 
or copper hue. The purpose in holding the point 
of the instrument on a piece of cold polished iron 
or steel is. that the heat there may be subject 
to complete control. The precise shade will be 
governed by the purpose for which the instru- 
ment is to be used; if for a drill, the edge or 
point should be of a light straw color; indeed, 
some operators prefer to have them scarcely 
chano^ed at the cuttinof eda^e, while excavators 
and chisels should be brought to a deep straw or 
copper color; this will be modified, however, by 
the manner of working the steel, and its quality. 
Skillfully hammering steel at a low heat — below 
a red — adds much to its quality for a fine cutting 
instrument, and gives an improved texture. In- 
deed, some assert that those instruments that 
can be forged to nearly their proper shape, can be 
as well, if not better, tempered by the hammer as by 
any other means. 

The instrument is then to be polished by the 
emery wheel and dressed up with the oil-stone. 
Of the various methods of tempering, the fore- 
going is equal in efl&ciency, and in convenience 
superior, to any other. 



124 



INSTRUMENTS FOR FILLING. 



FILLING INSTRUMENTS. 

For introducing and consolidating fillings, a 
great variety of instruments is in use. In every 
form in which gold is employed for filling teeth, 
the pliers are required for taking up the pieces 
and placing them in the proper position in the 
cavity; in cylinder or block-filling they are in- 
dispensable. These instruments are made of dif- 
ferent forms and sizes — of such forms as to facili- 
tate access to cavities inconveniently located ; of 
different sizes, to accommodate cavities of various 
capacities. For a large majority of cases, they 
require a slight curve, about half an inch from the 

Fig. 32. 




point; for some cases, however, the curve should 
be a right-angle. (Fig. 32.) 

The points of the pliers when closed should 
present such a form as to be used, to some ex- 



FILLING INSTRUMENTS. 



125 



tent at least, for consolidating the gold. This 
instrument should be about five inches long. 

The forms of condensing instruments may be 
multiplied to an almost indefinite extent. They 
are all, however, but modifications of two or three 
general principles. The particular form of the 
plugging point will be determined by the form 
in which the gold is used. With non-cohesive 
gold, small square, or round, sharp points of 
various curves are required. These points are 
easily kept in proper condition, and in some in- 
stances are used for years without any change 
or repair. 

A favorite method of filling with non-cohesive 
gold, by many excellent operators, is in the use 
of cylinders or blocks ; for this method, instru- 
ments especially adapted have been devised, which 
the following cut represents. 

Fig. 33. 




126 



INSTRUMENTS FOR FILLING. 



Fig. 34 is square from the curve to the point, 



Fio;. 34. 




and is used in the same manner, and for nearly 
the same purpose, as Fig. 33. 

For introducing and condensing key-blocks — those 
intended to bind the filling in place — Fig. 35 is 
the proper form. 

Fi2. 35. 




Figs. 36 and 37 are designed for condensing 
the surface of crown fillings, in the superior and 
inferior molars respectively. 

Fig. 36. 



riLLIXG INSTRUMENTS. 
Fio;. 37. 



127 




The instruments represented by the following 
are for condensing the surfaces of proximal fillings. 



Fi2. 38. 




Fig. 39 represents round right and left condens- 
ing points, to be used in filling proximal cavities. 



Fig. 39. 




Figs. 40 and 41 are flat, right and left condensing 
points, for same cavities as Fig. 39. 

Fis. 40. 



128 



INSTRUMENTS FOE FILLING.' 
Fig. 41. 




I 



The following cuts represent a set of filling in- 
struments devised and arranged by Dr. W. Gr. 
Redman. 



Fig. 42. 




They constitute probably the most complete set 
made, for filling with blocks or cylinders of non- 
cohesive gold. They are made with ebony or ivory 
handles, and are used with hand force only. 



FILLIXa INSTRUMENTS. 



129 



With cohesive gold in any of its forms, the 
points all require to be serrated. There are three 
or four varieties of these, which it will be proper 
to describe. The first is square, and slightly 
bent about half an inch from the end, which is 
formed into four or six definite sharp points with 
the edge of a thin file. Of this variety there 
should be about five sizes, the largest entering 
No. 18 of Stub's gauge, and the smallest No. 38. 

Fis. 43. 




The former should have six points, and the other 
two sizes four. (Fig. 43.) The cuts upon these 



Fig. 44. 




are made directly across the end. 

variety the end is rounded, and the file placed 



130 



INSTRUMENTS FOR FILLING. 



upon it at an acute angle with the side of the 
instrument, and the cuts, three in number, are 
made to the centre of the point, which thus 

Fig. 45. 




becomes triangular, or three-pointed, from a com- 
mon centre. (Fig. 45.) Four or five sizes of 
these may be employed, ranging from 18 to 26, 
Stub's gauge. A thin double point, from 26 to 28, 
is in many cases very valuable. Instruments with 
a condensing surface on the side, instead of the 
end, will frequently be required for filling lateral 
cavities ; these may be denominated lateral plug- 
gers. (Fig. 46.) This condensing surface should 

Fiff. 46. 




also be serrated, as already described. An in- 
strument square at the point, ranging from 18 
to 22, and cut upon the end by passing it along 
the cuts of a file both ways, thus making a large 



FILLING INSTRUMENTS. 



131 



number of small serrations at right angles across 
the point, is valuable for consolidating the sur- 
face of a plug. (Fig. 47.) Operating superficially, 
on the principle of the more deeply serrated in- 

Fig. 47. 




struments, it yet leaves the surface free from 
deep pits or indentations, and still so impressed 
that it will receive and retain more gold, if neces- 
sary, as it would not do if the end of the in- 
strument was perfectly smooth. A smooth-pointed 
instrument or burnisher may be applied after all 
the gold has been added. 



Fig. 48. 




Fig. 48 is an instrument with file-cut sides. 
It is valuable for dressing down proximate fillings 
to a uniform surface. There may be two, one 
with the sides parallel with the shaft, and one 



132 



INSTRUMENTS FOR FILLING. 

Fig. 49. 



= 1111' 




with its sides transverse to the shaft; it termi- 
nates in a sharp edge. 

In considering this subject thus far, the aim 
has been to present the principles that should 
be embraced by instruments for properly tilling 
the various classes of cavities that are presented. 

Within the last ten years great changes and 
improvements have been made in this class of 
instruments, especially with reference to classifying 
and systematizing them. 

It will be seen by the accompanying illustrations 
that considerable attention has been given in this 
direction, Fig. 49 presents Dr. W. H. Atkinson's 
" Omega" pluggers. 

Those who have become familiar with these 
instruments prize them very highly. 

Dr. F. Abbott's set of pluggers are also regarded 
highly by many. (Shown in Fig. 50.) 



'ig. 50 A. 



FILLIXG INSTRUMENTS. 

Fiff. 50 B. 



133 



Fig. 51 A. 



g i 



i I ^ = 'Oil 




1 li 11 11 

This cut represents Dr. Lewis Jack's " Matrix" 
pluggers. They are designed for and are well 
adapted to operations in which the matrix is required. 

Fig. 51 B. 




Fig. 52 represents Dr. R. W. Varneys set of 
pluggers. These were among the first regularly 
arranged sets of pluggers, and in some respects 
superior to any that preceded them, and became 
very popular. 

Fig. 53 represents Dr. C. R. Butler's set of 



[I 



134 



Fig. 52 A. 



INSTRUMENTS FOR FILLING. 
Fiff. 52 B. ' 



r r 



Fig. 5; 



(!' 



f f f^t 



J> 




11 II I I I 1 1 I 
pluggers, dilFerent in some respects from all the 
others, but excellent nevertheless, and better adapted 
for some cases. 




I 

n 

Fig. 54 shows in many important respects the most 
perfect set o^ plugging instruments ever made. They 
! ^ are the result of long and patient investigation ; they 

J will be at once recognized as the work of Dr. Cory- 
L^ J don Palmer. 

The following cut illustrates them as well as the 
engraver's art can do it. 



FILLING INSTRUMENTS. 
Fiff. 54. 



135 




136 INSTRUMENTS FOR FILLING. 

A minute description of each, with the direct- 
ions for its use, is given in section B, in the 
Appendix. 

In many cases a valuable instrument for con- 
solidating is the plugging forceps, the general 
form of which, except the beaks, is that of the 
ordinary straight extracting forceps. The beaks 
are formed into sockets for the reception of the 
plugging points, one of which is of the common 
construction, but the other has a broad flat sur- 

Fig. 55. 



face, to rest against the tooth. (Fig. 55.) This 
instrument is applicable only in certain cases, prin- 
cipally in filling proximal cavities. Its main ad- 
vantage consists in its capability of applying a 
strong pressure upon the filling, without affecting 
the socket. Manipulation with it is less rapid 
and definite than with the ordinary condensing in- 
struments ; and with it, too, there is much danger 
of fracturing friable teeth. 

There has been within the last few years very 
great improvement made in the serrated plugging 



FILLING INSTRUMENTS. 



137 



instruments — those employed for working cohesive 
foil. It consists in delicacy and perfection of form, 
a large addition to the variety, and a good system- 
atic arrangement. 

These instruments are now manufactured and 
put up in sets, embracing every requisite form, num- 
bering from forty to sixty ; this includes surface 
condensers and burnishers. 

The profession is largely indebted to the efforts 
of Drs. Palmer, Atkinson and Abbott, of New 
York, for the perfection obtained in the production 
of these instruments. 



THE FILE. 

Of this valuable and indispensable instrument 
there are a variety of forms used by the dentist. 
The thin files (Fig. 56) are chiefly applicable to 

Fig. 56. 




the anterior; the thick, heavy, knife-shaped (Fig. 



138 



INSTRUMENTS FOR FILLING. 



57), to the posterior teeth. The latter, to facilitate 
their approach to the points operated upon, have 
various curves, some single, others double ; the 
double being preferable, since they bring the handle 
of the instrument on a line with its cutting 
edge. The cuts upon this instrument, too, are 

Fig. 57. 



illiliilllllllillllllllllllillllllllllllllliiliiiil iilillili 





quite various ; in size ranging from very coarse to 
very fine, and in obliquity from a line almost at 
right angles across it to one at an angle of forty- 
five degrees. These cuts, too, are either single 
or double, the double being those made across 
one another. The single, however, are preferable 
for all operations on the teeth ; and the more ob- 
lique are to be recommended, since they cause 
less of that jarring, unpleasant sensation to the 
patient. 

There are in use various forms of file-carriers, two 
of which are represented in Figs. 58 and 59. Fig. 



THE FILE. 



Yicr. 58. 



139 




59, denominated "Redman's file-carrier," is an excel- 

FifT. 59. 




lent instrument, one principal advantage of which 
consists in the facility with which it may be changed 
from the one side to the other. Files are made 
adapted to the instrument : the chief advantage of 
which is, that it retains the file much more firmly 
than it can be held in the fingers. These carriers 
are made with a variety of curves, to accommodate 
different positions. There is also a great variety of 
small file-point instruments for dressing down fill- 
ings, the more important of which are represented 
in Fig. 60. 



140 



INSTRUMENTS FOR FILLING 

Fig. 60. 




The Use of the File. — When a separation of the 
teeth is requisite, preparatory to filling, it is fre- 
quently accomplished, either in whole or in part, 
with the file. Principally, in such a case, its use 
is restricted to finishing and smoothing, after the 
greater portion of the work has been done with 
the heavy cutting instrument, or in dressing off the 
thin, attenuated edges. The file is valuable for 
removing superficial decay, being called into frequent 
requisition in caries of this kind. It is employed to 
dress off roots preparatory to the insertion of pivot 
teeth, for which purpose it is required to be of a 
round or half-round form. It is used for dressing off 
sharp portions or edges of the teeth, that may be 



THE FILE. 141 

injurious to the soft parts, and in some cases for 
dressing down a tooth that is elongated. In finishing 
many fillings it is almost indispensable. It was for- 
merly used to some extent in the treatment of irregu- 
larity ; but for this purpose it has been abandoned. 

Mode of Using the File. — The patient should be 
conveniently seated, with the head on a firm support, 
and under the control of the operator, who should 
occupy a position at the right of the patient, in most 
cases, so disposing the head of the latter as to give 
free access to that point which is to be operated 
upon. In manipulating with the file, considerable 
skill and delicacy are requisite. It should not be 
held with a stiff, unyielding grasp, so as to catch 
and jar, but should be applied with a gentle pressure, 
a-nd drawn across the tooth with a free and flexible 
motion. It should be frequently moistened, and not 
allowed to clog with the filings, being kept free of 
these by repeated applications of the brush. A 
sharp, new file, with a quick, light movement, will 
cut far more rapidly, and less unpleasantly to the 
patient, than one that is dull or clogged, applied 
with a heavy pressure. If the tooth bone is sensi- 
tive, the file should be moistened in warm water. 
For cleansing files when clogged with dentine, the 
wire brush in common use is quite efiicient. Every 
operator should have one at hand. The form of a file 



142 INSTRUMENTS FOR FILLING. 

may be changed by drawing the temper, bending it as 
desired, and then re-tempering it. It is better, how- 
ever, to have them made of the proper form at first. 

The teeth, while being filed, should be supported 
by the fingers, or by an instrument for the purpose; 
or a cork or piece of soft wood may be inserted 
between the tooth being filed and the teeth of the 
opposing jaw, and the pressure thus used as a sup- 
port. The tooth being sustained in this manner, 
there is less jarring experienced by the patient, and 
less liability to produce irritation of the periosteum. 
When filing the anterior teeth, it is generally better 
to hold the file in the fingers. For filing the incisors 
and cuspids, a thin, bevel-edged file is to be pre- 
ferred. In dressing a tooth with a file, the last that 
is used should be a fine one ; after the application of 
which, the surface operated upon should be made as 
smooth as possible with a stone and burnisher, or 
with a buff and rotten-stone. 

In separating teeth with the file, where but one is 
decayed, care should be taken not to cut the sound 
one. For this purpose, it will usually be necessary 
to have a safe sided file — one side smooth to present 
to the sound tooth ; and even then the cutting edge 
should be somewhat beveled from the safe side, that 
the sharp angle of that edge may not rasp the sound 
tooth ) in no case of this kind should a square-edged 



THE FILE. 143 

file be used. In cases in which it is necessary to 
file teeth that are somewhat loose in the sockets, 
and whose periosteum is in a state of irritation, to 
build up a wall of plaster of Paris round them, per- 
mitting it to harden, will very much facilitate the 
operation. Perhaps a preferable method, in some 
respects, for accomplishing the same object, is to 
mould softened gutta-percha to the tooth and the 
parts about it. After it has become hard, hold it 
firmly in place while the filing is accomplished. 
Either of these methods will be found valuable in 
cases where it is necessary to dress off a considerable 
portion from the end of one or more of the inferior 
front teeth. There are some teeth upon which the 
use of the file is hardly admissible ; as, for instance, 
those which are highly predisposed to inflammation 
and sensitiveness of the dentine. The teeth of 
young persons, being often of this character, should 
be filed with great caution ; but, in general, those of 
adults may be filed, if properly done, with more 
freedom. The file should not be used upon the 
teeth when the periosteum, the gums, or the mucous 
membrane is diseased, or strongly predisposed to 
such a condition. It should never be used for the 
correction of irregularity of the teeth, especially 
when they are sound ; nor should it be employed to 
separate sound teeth to introduce clasps. 



144 INSTRUMENTS FOR FILLING. 

Filing the teeth is an operation against whicli 
there has been, and still is, much prejudice, though 
without sufficient cause. Whatever injury results 
from this operation, is from the imperfect manner 
in which it is performed, and from subsequent 
neglect of the tooth which has been subjected 
to it. A tooth skillfully treated with this instru- 
ment, and properly cared for afterward, will not be 
more liable to decay at the point operated upon than 
at any other where the dentine may be exposed. 



CHAPTER Y. 

SEPARATION OF THE TEETH. 

In most cases of proximal decay, the teeth, before 
the operation of filling can be performed, must be 
separated; though cases are not unfrequent where 
the space between them is sufficient to admit of free 
manipulation without this preliminary. An imper- 
fect accomplishment of this first step in the process 
of filling is a prolific source of the many failures, in 
proximal cavities, to attain to efficient and durable 
results ; for unless this step be thoroughly performed, 
so as to make room for the free introduction and 
use of the various instruments requisite, no part of 
the work can be complete. Though the most com- 
mon object for which teeth are separated is to 
obtain space for free manipulation with the instru- 
ments in filling, yet there are various other objects 
for which they have been separated, but many of 
which are now better accomplished by other means. 
It is sometimes necessary to cut away more than 
would otherwise be requisite, in order to remove thin, 
friable edges of the cavity, so as to obtain sufficiently 



146 SEPARATION OF THE TEETH. 

firm borders. Teeth are in some instances separated 
for the introduction of clasps^ — a practice always to 
be deprecated, since it usually proves highly injurious. 
Though the practice was once very common, yet 
most if not all the best operators have now, with 
good reason, abandoned it altogether. At one time, 
too, it was a general practice to separate the teeth 
with the file to relieve a crowded condition ; but this, 
also, has been abandoned. 

There are two methods of separating the teeth : 
the one, to cut aw^ay a portion ; the other, to force 
apart by pressure, acting upon one or more teeth, as 
the circumstances admit. Formerly, all separations 
were effected with the file, and this of very crude 
form and cut, by which instrument, especially in 
unfavorable cases, much injury has been done. 
Though the file is a valuable instrument, one that 
none other could supply, yet, for removal of any. 
considerable portion of dentine, it is not to be recom- 
mended. Its action upon inflamed dentine is exceed- 
ingly painful, besides being tedious and wearisome to 
patient and operator ; it is also liable to irritate the 
periosteum, and to increase inflammation. When a 
separation is to be made that requires the removal of a 
considerable portion of the tooth, the chisel, or heavy 
cutting instruments, illustrated on pages 102 and 
103, are to be preferred. These, if of the proper form 



SEPARATION OF THE TEETH. 147 

and temper, and in good condition, are very efficient 
for the purpose, performing the work far more rapidly 
than the file, and far less unpleasantly to the patient. 
They effect the removal of sensitive dentine with but 
little or no pain, and without liability to increase the 
inflammation, or to produce irritation or disease of 
the periosteum. The force of these instruments is 
sustained by the entire attachment of the tooth, their 
pressure being applied almost in a line with its axis. 
Besides, by their use, the contiguous teeth are not 
liable to injury, as by the use of the file they often are. 
The manipulation with these instruments is very 
simple. For separating front teeth, the instrument 
is firmly grasped in the hand, the thumb placed on 
the points of the teeth, and the edge applied at the 
point or crown surface of the tooth from which the 
portion is to be removed, and pressed gradually 
toward the gums, but not thrust into the interval as 
a wedge before it has freely cut its way. In this 
manner, as much of the dentine as it is desirable to 
remove is cut off in a few moments. This class of 
instruments is invaluable for forming the V-shaped 
spaces between the bicuspids and the molars that 
have been popular with many operators, but are 
pointedly condemned by others. It requires a pro- 
longed use of the file to make these separations pro- 
perly; and hence the practice of attempting to fill 



148 SEPARATION OF THE TEETH. 

proximal cavities without any separation at all, by 
operating through a small opening at the crown angle 
of the tooth, or a small hole drilled through its outer 
or inner portion. With the heavy cutting instru- 
mentSj points upon the teeth that the file cannot 
touch are approached and operated upon with facility. 
Another method of effecting the same kind of sepa- 
ration is, by the use of the corundum disks, used 
with the dental engine. 

The profession is indebted to Dr. Robert Arthur 
for devising and rendering practicable this very valu- 
able appliance. 

These disks, as seen in the following illustration, 
are made of various forms, suitable to meet all cases. 

Fiff. 61. 




For using the disks, carriers have been devised 
and made. These should possess three qualities, viz. : 
ready adjustment to the hand-piece of the engine ; 
facility of attachment and release of the disk ; and 
the easy change of the disk to any desired angle with 
the shaft containing it. That invented by Dr. Geo. 



SEPARATION OF THE TEETH. 



149 



H. Gushing possesses these qualities in a marked 
degree, and is very effective. 

The dotted lines in the figure show the angular 
range of movement of the disk upon its shaft. 

Fig. 62. 




For convenience and safety in using the disk, a 
shield or covering is adapted to it that effectually 
protects all parts except that operated upon. 

Fig. 63. 




By means of this instrument, separations of little 

more than a mere opening to the largest V-shaped 

space can he readily made, and it is claimed with 

. equal if not greater ease to the patient than by any 

other method. 

Skill and experience are required for their facile use. 

It is claimed that the use of the disk will 
largely supersede that of the file for separating teeth. 

But the method of separation by pressure is in 



150 SEPAEATION OF THE TEETH. 

many cases to be preferred, especially in the case of 
anterior teeth, whose natural form it is important to 
preserve. 

Till within a comparatively recent period, it has 
been the general practice to separate by gradual pres- 
sure ; and it is even yet the favorite method with 
some operators. But in almost all cases where 
separation is to be made by pressure, it can be done 
at once quite as well, if not better, than to prolong 
the process through several days ; there is economy 
of time, and the patient has far less to endure, and 
there is less liability of doing injury to the teeth or 
the parts about them. 

The anterior teeth, or those of single roots, yield 
very readily to a strong separating force, applied in 
the form of a wedge, notwithstanding the teeth may 
all be in contact with each other ; though in some 
cases the teeth are so firmly set, and the parts about 
them so dense and unyielding, that it is with great 
difficulty they can be moved, without too much 
violence to the parts. It is not generally practicable 
to attempt to separate the molar teeth by pressure. 

The method of effecting immediate separation is 
very simple ; it consists in forcing a wedge of some 
fine-grained wood of medium resistance — orange or 
box wood — between the teeth to be separated, either 
by pressure with the hand, or, better, by the blows 



SEPARATION OF THE TEETH. 151 

of a mallet. The Tveclge should be driven in at the 
necks of the teeth ; before this, however, a shield- 
wedge should be put in between the necks of the 
teeth against the septum of gum; it should be of 
such form as to retain its position while the chief 
wedge is being driven in ; and when they are very 
firm, an assisting wedge may be used, inserted be- 
tween the points of the teeth, and receiving strokes 
alternately with the other. The assisting wedge 
should be of very dense wood, and driven in with 
great care, for its leverage upon the teeth is very 
great. When the required space is obtained, the 
wedge at the necks of the teeth should be driven 
tightly in, and the other withdrawn. If all the teeth 
in the vicinity of those to be separated stand in con- 
tact, the resistance to separation, whether by imme- 
diate or gradual effort, will be greater. 

Two forms of appliances, denominated separators, 
invented by Dr. Jarvis, are very valuable aids in the 
separation of the teeth. The one is for separating 
the anterior and the other the molar teeth. The 
former is described as consisting of two wedges ap- 
proaching and passing each other ; being thus drawn 
together by a thumb-screw, making gradual and 
prompt separation where it is applied. 

Its operation is much more acceptable to the patient 
than that of the ordinary wedge driven with the 



152 SEPARATION OF THE TEETH. 

mallet. It will be found useful in making room for 
passing rubber-dam between crowded teeth. It may 
also be used to advantage in connection with the 
wedges. 

Fig. 64. 




That for the molars consists of a properly-formed 
piece of steel, bent upon itself, with the ends formed 
to fit the outer and inner portions of the proximate 
surfaces of two adjoining crowns. 

These jaws are forced apart by the action of a 
screw, which passes through one and against the 
other. 

This form is applicable to all the bicuspids and 
molars. It does not touch the gum or injure the 
teeth, neither does it cause much pain. 

The appliance may remain on the teeth in some 
cases while an operation is being performed ; other- 
wise a wooden wedge should be inserted between the 
teeth. It is represented by the following figure. 

The rapidity with which the operation may pro- 
ceed, and the extent to which it may be carried, 
will be determined by the tolerance of the parts to 
the movement, which should not be greater than the 
elasticity of the tissues will permit; not the slightest 



SEPARATION OF THE TEETH. 153 

laceration or rupture should be made ; again, great 
care should be observed, lest strangulation of the 
vessels that enter the roots, pass to and supply the 

Fig. 65. 



pulp, be effected ; this would be far more liable to 
occur in the teeth of young persons, or before matu- 
rity. There is in adults, however, a great diversity 
in their susceptibility to injurious influences. 

Many operators still prefer gradual separation by 
pressure. In order to secure the most successful 
results, the conditions of the parts should be strictly 
observed. The gums, periosteum, etc., should be in 
a healthy condition; for much injury may be done 
by attempting to separate teeth by pressure, when 
the contiguous parts are in an irritable state. In 
persons of a neuralgic diathesis, in those whose vital 
energy is weak, and particularly in those whose con- 
stitutional tendency is inflammatory, this operation 
is scarcely admissible. If, in such cases, it is at- 
tempted at all, it should be proceeded with very 
carefully and gradually, and should be preceded by 
constitutional treatment. There are many cases in 



154 SEPARATION OF THE TEETH. 

which it is best to make the separation partly by 
pressure, and then to complete it by dressing off the 
thin, friable edges of the cavity with the cutting 
instrument or file. Whether the process is to be 
wholly or only partly accomplished by pressure, 
should be determined beforehand. 

Various materials have been employed for sepa- 
rating the teeth by gradual pressure, the chief of 
which are cotton, wood, India rubber, and ligatures. 
The condition and character of the parts to be ope- 
rated upon will indicate the material best adapted 
in any given instance. In a good constitution, with 
the teeth firmly set, and the contiguous parts healthy, 
wood or India rubber may be applied ; but in cases 
of an opposite character, a more yielding and tract- 
able material is indicated. The degree of pressure 
to be applied and continued will be determined by 
the susceptibility of the parts to irritation. Soreness 
usually occurs in a few hours after the introduction 
of the material. The pressure should be gradual and 
constant, slight at first, and increased in force as the 
patient will bear ; the increase being made every day, 
and continued till ample space is obtained. The time 
necessary for the completion of this process is from 
ten to twelve days ; only one separation should be 
made at a time. The teeth should be retained apart 
till the soreness has abated, before the operation. 



SEPARATION OF THE TEETH. 155 

If not thus retained too long, they will return to 
their former position. It is by some supposed that 
separation by pressure is admissible only in the case 
of the young, or those under thirty years of age. It 
is true that they are the most susceptible ; but the 
operation is, under favorable circumstances, proper 
at any age. 



CHAPTER VI. 

FILLING TEETH. 

The operation of filling teeth is an interesting and 
important one, requiring for its successful accomplish- 
ment peculiar talent and large experience. It is the 
only means as yet ascertained of completely effecting 
the object for which it is employed, namely, arrest of 
decay and preservation of the organs. Therapeutic 
agents avail hut little here, so low is the organization, 
and so feeble the vital power. Nature, so efficient in 
more highly-organized structures, does comparatively 
little in disease of the teeth toward arrest or res- 
toration. Yet, on the other hand, these organs are 
less liable to decomposition by the action of foreign 
substances ; indeed, well-organized enamel is almost 
invulnerable to any agents to which it is ordinarily 
exposed. The dentine, however, is more easily acted 
upon, and, when there is defect in the enamel, is 
very liable to injury. 

Scarcely an individual in our country arrives at 
mature age with a perfect set of teeth ; indeed, nine- 
tenths of our people have decayed teeth at an early 



EXAMINATION. 157 

period of life. Hence, for beautifying, preserving, 
and supplying these organs, art is in constant requi- 
sition; and in these respects great achievements 
have been made. In the operation of filling the 
teeth, especially, the achievements are conspicuous ; 
and here is scope for the highest skill. Every suc- 
cessive step in the process of filling a tooth demands 
a complete and conscientious application of the most 
efl&cient and best adapted modes and appliances of the 
art. In the following remarks it is proposed to analyze 
this whole process, examining, in their order, the vari- 
ous steps necessary to be taken, and endeavoring to 
inculcate the true methods of accomplishing them. 

EXAMINATION. 

When a case is presented, there should first be a 
thorough examination, since by this all the subse- 
quent work will be modified. For this purpose the 
proper exploring instruments should be at hand, 
w^hich should consist of a sufficient number and 
variety of fine sharp-pointed instruments, so formed 
and curved as to be readily brought into contact 
with every point of surface of the crown of every 
tooth, and indicate any defect that may exist. 

The accompanying cut represents the common and 
perhaps the best forms of this class of instruments. 



158 



FILLING TEETH. 



In addition to these, mirrors, reflectors and magni- 
fiers, when properly adjusted and skillfully used, are 
very valuable. 

Fig. 66. 





111 

There should be two or three sizes of mirrors, 
adjustable to any angle requisite to reach every 
point in the mouth efficiently. 

Reflectors are desirable for throwing light upon 
obscure or dark points. 

Magnifiers are important in examination of the 
teeth, to bring to view defective points that would 
escape detection by the unassisted eye. Every 
operator ought to have at hand at least three grades of 

Fig. 67. 




these. Mirrors and magnifiers are combined to some 
extent, but sufficient amplification and definition 



EXAMINATION. 



159 

The 



cannot be obtained in this way for all cases 
common mouth mirror is shown by Fig. 67. 

Mirrors and reflectors are made adjustable upon 
the finger of the operator, as in 

Fig. 68. 





Reflectors adjustable on the rubber-dam clamps 
serve a valuable purpose, and should always be at 

hand. Shown in 

Fiff. 69. 





They are also attached to the rubber-dam clamps, 
which makes, for many cases, a very convenient 
arrangement. 

Fig. 70 is a magnifier, to be used on the finger of 
the operator. The chief use of the magnifier, how- 
ever, is for examination rather than for operating. 



160 



FILLING TEETH. 
Fig. 70. 




The points to be noted in the examination are as 
follows : 

The temperament ; the present health ; the consti- 
tutional tendencies ; the secretions, — the saliva and 
mucus ; the mucous membrane and the gums ; the 
constitution and condition of the teeth ; the num- 
ber of them remaining in the mouth; the number 
affected; the extent and nature of the decay, and 
the character of the agents producing it. By the 
examination we ascertain how to proceed in the 
operation; if much or but little labor is required; 
whether the operation will be a simple or a difficult 
one; and if difficult, what circumstances render it 
so ; and, besides, some conclusion is arrived at in 
regard to the precise means to be employed for 
obtaining the desired result, as well as the perma- 
nency of that result. 



OPEXIXG. 161 

OPEXIXCt. 

The next step is to open the cavity of decay, so 
that it may be approached and operated npon at all 
points. The particukr manner of performing this is 
determined by the extent of the deca}', and its posi- 
tion upon the tooth. In all cases the opening should 
be such as to give free access to all parts of the 
cavity, for effectually removing the decayed portion, 
for perfectly forming the cavity, and for introducing, 
thoroughly consolidating and finishing the filling. In 
central crown cavities of the molars and bicuspids, 
the projecting or pendent portions of enamel should 
be cut away. There are cases, however, where such 
portions are firm and not liable to be broken, and 
where they can be well sustained by filling under, in 
which it is admissible to leave some projection. This 
is true of only those teeth which are of good, firm 
texture. There are two objections to these abrupt 
projections of enamel : it is very difficult, and in 
many cases impossible, to fill perfectly beneath such 
portions ; and again, they are liable to be broken 
down during mastication. 

For opening up these cavities, in many cases the 
bur drill alone will be quite sufficient ; those of dif- 
ferent sizes being employed, to open up the orifice 
frraduallv. so that too much violence may not be done 



162 



FILLING TEETH. 



to the teeth. In all very small cavities, the bur is 
all that is required, except in decayed fissures, and 
for these the fissure bur is almost indispensable. 

In cases where the decay is more extensive, and 
the cavity larger, the chisel or heavy cutting instru- 
ment, in connection with the drill, will be found very 
useful. Fig. 71 represents valuable forms of these 
instruments. 




Fig. 8, page 103, represents instruments for this 
purpose, of various forms and sizes ; they may be 
used either with hand force or the mallet. In cases 
where much cutting is required, the latter method is 
preferable, being more rapid in execution, and less 
objectionable to the patient. 

The fine file or bur should always follow the use 
of the chisels, to give a smooth and even surface to 
the part upon which the cutting has been made. 



REMOVAL OF DECAY. 



After the cavity is opened, the next step in order 
is the removal of the decayed dentine. As a general 



REMOVAL OF DECAY. 163 

riile^ this should be entirely removecl. There is, 
however, some variety of opinion upon this subject. 
This difference of opinion is in regard to cases 
where an entire or a partial decomposition of the 
dentine has taken place quite to the pulp, where, by' 
its removal, the pulp would be exposed. It is main- 
tained by some that decayed dentine affords a better 
protection to the pulp than any artificial covering ; 
and hence it is better to let it remain, since its 
adaptation is more complete ; and it is not in every 
sense a foreign substance. 

On the other hand, it is contended that the 
decayed dentine, being in an abnormal condition, 
will irritate, and in many cases ultimately destroy^ 
the pulp. And again, that there is danger of 
making undue pressure upon the pulp, in filling on 
such softened portion. 

In many cases it is maintained that partially 
decomposed dentine will become dense again, if 
protected from the influence of foreign agents that 
decompose it. This sometimes would seem to be 
true. For in some cases where fillings have been 
introduced into cavities, at the bottom of which a 
portion of softened dentine covered the pulp, on 
removing them in from one to five years afterward, 
all parts of the cavity were found to be equally and 
normally dense. This, perhaps, would occur only 



164 FILLING TEETH. 

in good constitutions, and under favorable circum- 
staiices ; but with sucb constitutions and circum- 
stances, where the softening is not too extensive, 
and the decomposition but partial, it may be per- 
mitted to remain, with a strong probability of a 
favorable result. This would certainly be better 
than to cut it all away, and expose and perhaps 
wound the pulp, and then endeavor to cover it with 
some wholly foreign material that would not be 
perfectly adapted to it, that would press a little too 
hard at one point, and not touch at another, and that 
would be quite as liable to be pressed down on the 
pulp as the softened dentine. 

In this discussion, much depends upon the point 
whether partially decomposed dentine can retain its 
vitality. This it is not now proposed to consider. 
There are some particulars in regard to the removal 
of decay, however, about which there is no diversity 
of opinion : first, that all decomposed dentine should 
be removed from all parts of the cavity, where the 
pulp would not be exposed or injured thereby ; and 
that in all cases it should be entirely removed from 
the lateral walls of the cavity, and especially from 
the vicinity of the orifice. Even discolored dentine 
should be removed from this part, unless weakening 
of the borders or walls would thereby be occasioned. 

Dentine often becomes changed in color when 



EEMOVAL- OF DECAY. 165 

there is no apparent decomposition ; such portion is 
usnally. though not always, without vitality. It is 
not important to remove such changed portion, 
except for the appearance of the tooth ; it will 
produce no change upon the living or normal part 
beyond it : and it is better material to be in contact 
with the livine part than anv metal of which a 
filling; mav be made. 

Decayed dentine is readily removed with the 
excavators. In any given case, such instrument 
should be selected as would be best adapted for the 
purpose, as well in regard to size and the form of 
its edge, as to the curvature, or inclination of its 
shaft. The edge of the instrument should come 
upon the walls of the cavity at such an angle as to 
accomplish the work most efficiently. It should be 
very sharp, and pressed firmly to the bottom of the 
decay at one side, so as to remove the principal part 
at one cut. So far as possible, the direction of the 
cutting should always be from the nearest point of 
pulp exposure, toward the orifice of the cavity. With 
the proper instrument, and that in the right condition. 
all the decay shotdd be removed from any cavity 
by a few. firm, steady strokes. By this method 
less pain is caused the patient, and the work of the 
operator is facilitated. It is intolerable to think of 
being subjected to an awkward, clumsy hand, with 



166 FILLING TEETH. 

a dull, ill-shaped excavator, scratching upon the 
surface of a decayed tooth, for a length of time, 
apparently to the patient interminable. 



FORMING CAVITIES. 

The next step in the operation is the formation of 
the cavity. By this the cavity is so formed that it 
will well receive and retain the filling when properly 
introduced. In very few cases is the cavity of 
proper form when the decay is removed; hut in 
almost every instance more or less of the solid 
dentine must be removed to secure a proper form 
to the cavity. Much time, patience and labor are 
required of the operator for the proper accomplish- 
ment of this part of the work, and much endurance 
on the part of the patient. In this part of the 
work several particulars require consideration. The 
great object, however, is to give to the cavity such 
a form as will secure the most perfect adaptation of 
the filling to every point, and its permanent retention 
in place. The cutting for the formation of the 
cavity should be accomplished with the least possible 
loss of healthy dentine ; this is a point upon which 
good judgment should be exercised. The strength 
of the walls of the cavity, and the ability of the 
parts to Avithstand the pressure, both in the intro- 



FORMIXG CAVITIES. 1G7 

diiction and consolidation of the filling and in the 
act of mastication, should be well noted. It may be 
reo'arded as a rule from which there should scarcely 
ever be a departure, that the enamel should never be 
encroached upon, through the dentine, in excavating 
to eive form to a cavitv. When there is but a linino^ 
of dentine at any given point on the enameL after 
the decay is removed, it should remain for the 
preservation of the enamel ; it should not be cut 
through either by pits or by grooves, much less 
should any considerable portion be removed. 

There are cases occasionally in which the dentine 
is wholly decayed, and its removal lays bare the 
enamel ; when such a case occurs, the enamel should 
be retained in as perfect a condition as possible, and 
no attempt made to form pits or grooves in it. The 
reason for this is found in the friability of the 
enamel. 

It may be regarded as an axiom, that where it is 
necessary to cut the healthy dentine to give proper 
form to the cavity, it should be done at that part of 
the cavity where the tooth will suffer least from the 
loss. The precise point and amount of cutting will 
be determined by the form and size of the cavity, 
and the amoimt of solid dentine remaining after the 
decay is removed. 

In small cavities where there is sufficient material 



168 FILLING TEETH. 

to work upon, the object is to give the cavity a 
regular form, and make the retaining points where it 
is most convenient. 

In large cavities, where one side of the tooth is 
weak, places must be selected for making the retain- 
ing points, that will least affect the weak point. 
Frequently, in proximal decays. of the anterior teeth, 
the labial and palatal walls are friable, and would be 
easily broken ; much cutting upon such walls would 
not be admissible. Again, the decay often extends 
toward the point of the tooth, down to the union of 
the labial and palatal plates of the enamel ; in cases 
of this kind, all that can be done at this point is to 
remove the decay ; and fracture will sometimes 
occur even in accomplishing this. 

In some instances, as in the crown cavities of the 
molars, the cavity will be nearly or quite of proper 
form when it is perfectly opened up, and the decay 
all removed. This is the case when the decay is 
confined to a simple perforation of the dentine, 
without any considerable lateral extensions. In 
proximal cavities there is always more or less exca- 
vation of the solid dentine required, to give the 
cavity proper form. 

There is no definite rule for the formation of 
cavities, that will be applicable in all cases. The 
form will be modified by the tooth, the position of 



FORMING CAVITIES. 169 

the decay upon it, the extent and ramifications 
of the decay, and the manner in ^vhich it is to be 
filled. It is given, by some, as a rule, that the 
depth of a cavity should be equal to its least 
diameter. This is a direction, however, of no 
general application, for many cavities will be much 
deeper than the greatest diameter, as in crown 
cavities of the molars ; and the reverse will often 
occur, as in labial cavities of the superior incisors, 
and in proximal cavities of the molars, in which it 
would be impossible to make anything like an 
approach to this rule, without exposing the pulp, 
and even cutting through its chamber. 

A general direction, and one that we think good, 
and applicable in many cases, especially in crown 
cavities of the molars, and in almost any of the 
deep perforations by decay, is to make the walls 
of the cavity as nearly as practicable parallel with 
one another. This rule is applicable in almost all 
small cavities. 

In medium or large-sized cavities, it is admissible 
to leave them slightly larger at the bottom than at 
the orifice, if circumstances require ; a large cavity 
of this form can be perfectly filled, when a small 
one could not, from the fact that, in the former 
there is more room to operate in introducing, 
adapting and consolidating the filling. 



170 FILLING TEETH. 

Cavities that are larger within than at the orifice, 
should have their walls perfectly plaiiij smooth sur-* 
faces, free from transverse grooves or depressions, 
so that the gold may be accurately adapted to them. 

It is sometimes necessary to leave a cavity slightly 
larger at the orifice than at the bottom. This may 
be done by a diverging inclination of the wall of 
one or more sides of the cavity. When there is an 
inward inclination of the wall at one side of the 
cavity, the general form may be such as to retain 
a filling perfectly, for there may be two opposite 
sides parallel, or even divergent ; in that case, the 
axis of the cavity will not be in the direction of the 
centre of the crown. 

Two opposite sides may converge and the others 
diverge, and a filling be retained firmly. When two 
contiguous sides have the same converging inclina- 
tion, making the orifice larger than the interior, if 
the walls are smooth, plain surfaces, a filling w^ill not 
be retained ; but retaining points may be made by 
forming transverse grooves, or pits upon them, and 
by this means the filling be firmly retained. As a 
general rule, it will be necessary, when the orifice is 
larger than the cavity within, to make grooves or 
pits on the walls. For this purpose the diamond 
point excavator is invaluable. 

If the cavity is large, and the walls near the orifice 



FORMING CAVITIES. 171 

thin, and liable to be broken, the situation of the 
grooTes or under-cutting should be farther within the 
cavity than if the vralls are firm out to the edge. 
Sometimes it is best to make little pits at the bottom 
of such cavities for retaining points. In cases where 
it is necessary to make an under-cutting, one or two 
little transverse grooves upon one side will be suffi- 
cient, and in no case on more than two sides, leaving 
the others perfectly plain surfaces. 

In the formation of retaining points in difficult 
cavities, there is considerable diversity of practice — 
under-cutting and grooving have been Aery com- 
monly employed. Another method in common use 
is that of drilling little boles or pits into the dentine 
at the most favorable points, these taking different 
directions. This kind of retaining poiats is much 
better calculated to answer the piu'pose, in filling 
with crystal gold, or cohesive foil, than with the 
ordinary non-cohesive foil after the old methods. 
When these perforations are made at diff'erent 
inclinations, and then perfectly filled with cohesive 
gold of any kind, the filling will certainly be retained 
in place. For making these perforations, a small 
square-edged drill is the proper instrument. 

Such retaining points are seldom or never required 
in crown cavities of the molars ; but in proximal 
cavities they are frequently employed with gxeat 



172 FILLING TEETH. 

advantage. In forming them, great care should be 
exercised, lest the pulp-chamber is encroached upon 
by the instrument. In almost all cases, the proper 
point for forming them is in the cervical wall of the 
cavity. 

Some operators discard any definite retaining 
points, grooves, or angles, but aim, instead, to give a 
general retaining form to that part of the cavity in 
Avhich the filling is to be commenced, and upon which 
reliance is to be placed for its retention. The ad- 
vantage of definite retaining points is two-fold : first, 
to facilitate the introduction of the filling ; and second, 
its more certain retention after it is in position. 

Another particular to which attention should be 
given is the border of the orifice. It should always 
be an object to secure an even^ smooth and strong 
border to the orifice of the cavity. It is impossible 
to make a good finish with a rough, uneven border ; 
the filling is also more exposed to injury by mastica- 
tion. The integrity of a smooth, plain surface is 
retained under influences that would break up and 
destroy an uneven one. It is also very desirable 
to have a firm margin; to obtain this, it is often 
necessary to cut away more than would otherwise be 
desirable. A smooth, firm border should not be sacri- 
ficed for the form, and especially in the posterior 
teeth. It is very objectionable to some persons to 



FORMIXG CAVITIES. 173 

have the perfect form of the front teeth marred or 
changed ; hnt it should he remembered that even a 
front tooth one-third ent awav, and so filled as to be 
permanently preserved, is far more valuable than an 
artificial one. 

Another particular that should always he observed, 
is, to obviate all acute angles, and especially when 
they are in the vicinity of the orifice of the cavity. 
"These are seldom or never found in proximal cavities 
of the molars and bicuspids ; occasionally they are 
found in proximal cavities of the cuspids, and fre- 
quently in proximal cavities of the incisors, par- 
ticularly at that part of the cavity next to the 
cutting edge of the tooth. Such angles are very 
often found also in crown cavities of the molars and 
bicuspids, where there is an extension of the decay 
along one or more of the fissures of the crown. 

It is difficult — almost impossible — to fill perfectly 
a sharp anaie. and hence the necessity of obliterating: 
such when it occurs. This may be done either with 
a small delicate cutting instrument or with a small 
bur drill. It is an operation requiring great care 
and delicate manipulation, at least so far as the an- 
terior teeth are concerned. When a sharp angle 
occurs in the proximal cavities of the front teeth, 
it is usually near the cutting edge of the tooth, 
just at the union of the labial and palatal plates of 



174 FILLING TEETH. 

enamel. A small cliisel-shapecl instrument is very 
good for cutting out sucli angles : indeed, in fissures 
of crown cavities of molars, where the decay extends 
backward, the straight, chisel-shaped instrument is 
just adapted to this purpose ; but when there is an 
anterior extension, the instrument should be curved 
to almost a right angle, and forced down by pressure 
of the thumb of the left hand. The small burs and 
fissure drills represented by Figs. 20 and 22, used 
with the dental engine, will meet the requirements 
in such cases with great facility. Some good opera- 
tors recommend a slight reaming at the orifice of all 
cavities, where it can be accomplished. The object 
of this is two-fold : to remove the sharp angle at the 
orifice of the cavity, as it is liable to be fractured or 
roughened in putting in the filling; and to give a 
better margin to the filling. In making this bevel, 
the bur, if one is used, should be but little larger 
than the orifice of the cavity. The cutting should 
be but slight — just sufficient to remove the sharp 
corners ; much cutting here would give too thin and 
yielding an edge to the filling. 

EXCLUSION OF MOISTURE. 

The complete and certain exclusion of saliva and 
all moisture from a tooth that is to be filled, has 



EXCLUSION OF MOISTURE. 175 

ever, till within a comparatively recent period, been 
a great desideratum. A great many appliances and 
methods have been employed for the accomplish- 
ment of this object. The usual method was to pack 
about and around the tooth upon which an operation 
was to be performed napkins, bibulous paper, spunk, 
etc., retained in place by holders. These, in most 
cases, were effectual but for a short time, and when 
the flow of saliva was abundant, constant vigilance 
and effort were necessary to secure the proper ex- 
clusion of moisture. Quite a variety of instruments 
and appliances have been employed for holding in 
place these various paddings. Some of them were 
to be held by the patient, others were so formed as 
to clamp the rolls or pads firmly in place. 

None of these appliances had reference to check- 
ing the flow of saliva by compression upon the mouths 
of the ducts ; this, however, in due time was intro- 
duced. Various appliances and adjustments were 
made with this object in view. Pads of cloth, 
bibulous paper, spunk, and disks of pipe clay, were 
the principal things used for this purpose ; they were 
placed and held firmly on the mouths of the ducts 
by clamps, springs, &c. A good degree of success 
was in this way attained in some cases, in others it 
is impossible to close all the ducts 3 and in almost 
every instance these things stimulated an excessive 



176 ^ FILLING TEETH. 

flow of mucus. Filling the mouth in the manner 
just described was always objectionable to the 
patient, and in many instances could not be tolerated. 

In addition to all these things, various pumps 
were devised for removing the saliva from the 
mouth as it accumulated, all of which were more 
or less objectionable. 

All these modes and appliances have been super- 
seded by the introduction and use of the rubber 
dam and saliva extractor. For the former of these 
the profession is indebted to Dr. S. C. Barnum, and 
for the latter to Dr. J. E. Msk. 

The rubber dam is, by all those who understand 
its use, justly regarded as an invaluable boon. It 
can in any and all cases be applied so as to abso- 
lutely exclude moisture from a tooth or teeth while 
being operated upon. It does not, however, prevent 
the free flow of saliva into the mouth, and in most 
cases this occurs to a very objectionable extent, and 
either the patient must swallow it, — and with the 
rubber dam in place very few can do this, — ©r it must 
overflow from the mouth, which is very unsightly, 
inconvenient, and annoying, or it must be drawn 
from the mouth. 

About three years ago. Dr. Fisk made available 
the principle of the Giflbrd injector, devised the 
saliva extractor, a very valuable appliance indeed ; 



EXCLUSION OF MOISTURE. 



177 



one that with a constant stream of water performs 
its work perfectly. The following cut gives a sec- 
tional view of it. 

Fig. 72. 




An instrument constructed by Dr. George B. Snow 
for the same purpose gives promise of great useful- 
ness. In principle it is a compromise between the 
Gilford injector and the syphon. It requires for 
operation but a small amount of water — about one 
quart per hour. The water requisite for its work- 
ing is contained in a reservoir holding about two 
quarts. 

This instrument is very efficient and uniform in 
its operation. It is shown in Fig. 73. 

With either of these appliances, the mouth can be 
kept for any length of time entirely free from any 
excess of saliva. 

The rapid, easy and efficient application of the 
rubber dam is not attained without some manipula- 
tive skill and experience. It is prepared for dental 
purposes of three or four grades, in respect to thick- 
ness ; the thinnest is about as thick as a sheet of 



178 



FILLING TEETH. 



Fig. 73. common commercial note paper ; the 
other extreme would be represented 
by about six-ply of the same paper. 

This web should be made of rub- 
ber of the finest quality, and free 
from all foreign substances. Having 
selected that of the desired thickness, 
cut a piece six inches wide and from 
six to ten inches long; select the 
proper place or places for perforating 
it for the teeth ; for this, three sizes 
of punches will be required : one about 
a line and a half in diameter, for the 
molars ; one about a line in diameter, 
for the superior incisors and bicuspids, 
and one half a line, for the inferior 
incisors, and sometimes for small 
superior incisors. 

These punches are shown in Fig. 
74. The distance between the holes 
in the cloth should be from one line 
to two lines and a half, governed by 

the distance between the necks of the teeth to which 

it is to be applied. 

The following accessories should be at hand and 

ready for use before beginning its application to the 

teeth : 



EXCLUSION OF MOISTURE. 

Fig. 74. 



179 




Silk Thread. — That known as surgeons' or sad. 
dlers' silk is weU adapted to the purpose. There 
should be at least two sizes of this. 

For some cases the floss silk is better adapted 
than the thread. These should always be at hand. 

The clamps for rubber dam are indispensable ; they 
are of various forms and sizes, and are now made 
adapted to all the teeth ; and in addition there is quite 
a number of extras for special cases. 

The following cut represents the set for the 
superior teeth of the right side, each of which has 
been formed and adapted to the respective tooth upon 
which it is to be used. 

There are in the full set thirty-two, and a few for 



180 



FILLING TEETH. 



K. S.,1. 



R. S., 2. 



Fig. 75. 

K. S., 3. R. 




R. S., 5. 





special cases, thus making by far the most complete 
and efficient series of these clamps ever devised. 

The profession is largely indebted to Dr. Delos 
Palmer for the most efficient clamps that have been 
in use for several years, and wholly indebted to him 
for the very perfect set represented above. 

The clamps are usually placed on the teeth, after 
the rubber-cloth is drawn over them, for the pur- 
pose of retaining it in a proper position. Often- 
times, however, the rubber may be drawn over the 
clamp, and then both together be placed upon the 
tooth. This method is usually employed only when 
one tooth is to be protected. 

For this adjustment upon the teeth, clamp-forceps 
are in requisition. They are so formed as to pass 
into the curve of the clamp, and by pressure upon 
the handles, open it sufficiently to pass on to the 
crown of the tooth, the rubber then being drawn 
under the jaw^s of the clamp. 

Fig. 76 represents the clamp-forcep in common use. 



EXCLUSION OF MOISTURE. 

Fiff. 76. 



181 




1=82 



FILLING TEETH. 



The elastic strap, with clamps or catches attached, 
is necessary for holding away the upper free portions 
of the rubber-cloth (Fig. 77). 

Fig. 77. 





The weights, also, for holding out of the way the 
lower free portions of the rubber-cloth, are impor- 
tant. These are shown in Fig. 78. 

Various sizes and forms of wedges will be required; 
these should be prepared beforehand, or they may 
be made at the time they are to be used; their 
-adaptation to the peculiarities of the case in hand 
rather favors this course. 



EXCLUSION OF MOISTURE. 

Fig. 78. 



183 




Jarvis separators should always be at hand, to 
press apart any teeth that may stand so firmly m 
contact as to prevent the rubber from passing readily 
between them. 





Having now come to that point when the rubber- 
dam is to be applied, various questions and consider- 
ations occur : 

First. — Upon how many teeth shall the dam be 
placed ? 

The character of the operation will determine this. 
For a simple crown cavity of either a superior or 



184 FILLING TEETH. 

inferior molar, if the opening of the mouth is capa- 
cious, the embrace of one tooth may be, and often is, 
sufficient. If, however, the mouth be small, or the 
tooth unfavorably located, two or even three teeth 
should be included, even for such a cavity as just 
indicated. For filling proximal cavities, two or more 
teeth should always be included, and more fre- 
quently three or four. The difficulties liable to occur 
from the embrace of an insufficient number are : en- 
croachment of the cloth upon the locality of the ope- 
ration (the size of the mouth and its behavior will 
modify this, however), and the liability of leakage 
about the last teeth included in the embrace. 

A sufficient number should in every case be in- 
cluded to meet the requirements, and no more. The 
practice of placing the rubber upon eight or ten 
teeth, when two or three at most would be sufficient, 
should not be encouraged or allowed. It is a waste 
of time for the operator and an unnecessary annoy- 
ance to the patient. 

In the application of the dam, if it is to be put 
upon two or more teeth, it should first be placed 
upon that tooth which is most accessible, then upon 
the next one, and so on till all the selected ones are 
included. As the rubber is drawn over the crown of 
each tooth, the thread or floss should be passed 
between it and its neighbor, carrying down to the 



EXCLUSION OF MOISTURE. 185 

margin of the giiin the rubber that is between the 
holes ; this process should follow the application of 
the rubber to each tooth. 

The rubber will often pass with difficulty between 
the teeth, either because of firm contact or because 
of roughness upon the proximate surfaces of the 
teeth, the latter sometimes causing tearing of the 
rubber. To meet the former difficulty, the separ- 
ators (Fig. 79) may be used, and sufficient space 
readilv obtained to afford an easv passa^re between the 
teeth, and a very thin saw for the removal of the 
roughness ; this, however, should never be applied 
to the perfect surfaces of the teeth : and in respect to 
the rubber, moistening it with a solution of fine soap. 
of proper consistence, will greatly facilitate its pas- 
sage between the teeth. 

The rubber cloth now being upon the teeth, the 
elastic band with its clasp should be attached to the 
upper free border at each side, and drawn round the 
head sufficiently to keep them out of the way : then 
the thread, in connection with a small, properly-formed 
instrument, will be applied for turning the border of 
the rubber about each tooth down beneath the maro'in 
of the gum. the thread accomplishing this between 
the teeth and the instrument, at the labial and 
lingual surfaces. This is a part of the work that 
should be carefully and thoroughly performed ; the 



186 FILLING TEETH. 

absolute exclusion of the moisture depends much upon 
this. Ligatures are sometimes tied tightly round 
the necks of the teeth, for the purpose of holding 
the rubber in place about them. 

After this, the wedges, if required, should be in- 
troduced. The objects to be gained by these are : 
increase of space between the teeth ; to retain the 
septum of the rubber against the gum, and press the 
gum up somewhat, and thus effect greater security 
against the encroachments of moisture ; and to pro- 
tect the gum from injury by the instruments which 
are to be subsequently used. 

The weights should now be applied to the inferior 
borders of the rubber, in such a manner as to keep 
them in a desirable position. With the rubber dam 
thus adjusted, and the " saliva extractor" in proper 
order and in place, there will be no difficulty with 
moisture or an overflow of saliva in any case, and the 
succeeding steps may be conducted with the utmost 
security, so far as moisture is concerned. 

Some operators apply the rubber dam in almost 
every instance prior to the removal of decay and the 
formation of the cavity for filling ; and doubtless in 
many cases it is the preferable course, the only ob- 
jection to it being the prolonged inconvenience to 
the patient ; but for this there is perhaps full com- 
pensation, in the greater facility afforded in the 



I 



EXCLUSION OF MOISTURE. 



187 



removal of decay from and the excavation of the 
cavity ; with the entire absence of saliva and moisture, 
the work can be effected with greater rapidity and 
precision ; iniproper cutting is less liable to occur. 

After the rubber dam is properly adjusted, it is an 
easy matter, with bibulous paper or some similar sub- 
stance, to render the tooth and the part to be operated 
upon thoroughly dry. Every particle of debris, cut- 
tings of dentine, etc., should be removed from the 
cavity before it is filled. This removal may be 
effected by the small scoop-shaped instruments, of 
which there should be three or four sizes. In con- 
nection with these, the ''chip hlower^' or warm air 
blowpipe, illustrated in Fig. 80, may be advantage- 
ously used. 

Fis. 80. 




This instrument consists of a small blowpipe, with 
a cylinder an inch long and half an inch in diameter ; 
this is placed down within two inches of the point 
of the instrument. This cylinder is either made of 
very heavy metal, or filled with wire or something 
that will retain heat ; on the other end is attached a 



188 FILLING TEETH. 

stiff India-rubber ball, with an eyelet opening, one- 
fourth inch in diameter. By placing the thumb upon 
this opening and making compression, a jet of air is 
forced through the point of the pipe, and. the cylinder 
being previously heated, the temperature of the jet 
will be governed by that of the cylinder, and the 
velocity with which it is forced through the instru- 
ment. This jet thrown into a cavity that has been 
made as dry as possible by wiping, soon makes a 
very perceptible change, the walls becoming whiter 
than before. This we consider the m'ost desirable 
condition in respect to dryness that can be obtained. 

INTRODUCING THE FILLING. 

Having in all these steps for the preparation of 
the cavity made thorough work, the next thing to 
be accomplished is the introduction and consolidation 
of the filling. The manner of performing this part of 
the work will be governed by the kind of material 
employed, and also, somewhat, by the form of the 
particular material, as well as the method adopted. 
Some materials, as gold, for instance, may be used in 
six to eight different forms, each involving a prin- 
ciple peculiar to itself; and each of these forms is 
susceptible of being used in different ways. It is 
proposed to describe, as clearly and concisely as 



INTRODUCTION OF THE FILLING. 189 

possible, the various methods of filling that have 
been found efficient. This is the more important 
since different operators differ in their election of 
methods ; some preferring one, others another, — the 
result of mere choice, habit, or some peculiar fitness. 

The first method for consideration is that of filling 
with ordinary non-cohesive gold foil. The principles 
applicable to the use of this kind of foil also obtain in 
the use of foils of other metals. Gold is used far more 
than anything else. The common, and, indeed, the 
almost universal method of using foil, in the early 
periods of the profession, was in the form of a roll, 
or rope, as it is sometimes called. By this method 
the foil is cut into strips from one-third of an inch 
to two inches wide, the width being governed some- 
what by the size of the cavity to be filled. This 
strip is then rolled lengthwise, forming a loose roll. 
The compactness of the roll should depend upon the 
thickness of the foil, and the size of the points with 
which it is to be condensed ; the smaller the points, 
the more compact the roll may be. 

It may be introduced either with the condensing 
instrument or with the plugging pliers. If with the 
former, it is taken up at one end on the point 
of the instrument, and passed to the bottom of the 
cavity 5 and that portion within the cavity is then 
pressed firmly against the wall where it is desirable 



190 FILLING TEETH. 

to begin the filling. There is no definite uniform 
point in cavities at which to begin the introduction 
of the gold ; usually, however, in crown cavities of 
the molars, at the posterior wall. At whatever point 
the filling is commenced, the cavity should be so 
formed that it will retain in position the first portion 
of gold introduced ; and this may be done by forming 
a little pit or groove for its reception. This is a par- 
ticular that cannot with impunity be neglected. The 
gold should never change its position after it is 
pressed to the wall of the cavity ; for its position 
cannot be changed, except at a sacrifice of the adapta- 
tion, after it is condensed. The end of the roll being 
placed in the cavity, it is seized far enough without 
the caAdty to form a fold that will extend to the 
bottom, and protrude about one line beyond the 
border of the orifice. This fold is pressed firmly 
upon the preceding portion of gold and adjacent 
walls. Thus fold after fold is introduced, passed to 
the bottom of the cavity, and, protruding from the 
orifice, consolidated firmly; each portion as it is in- 
troduced should be well adapted to the walls of the 
cavity and the preceding portion of the filling. 

It is important to obtain as complete an adaptation 
of the filling to the walls of the cavity as possible ; 
and in order to accomplish this, the centre should not 
be filled too rapidly. The gold is thus introduced 



INTRODUCTION OF THE FILLING. 191 

fold after fold till the cavity is full. When it is filled 
to two-thirds of its diameter, the gold should then be 
adjusted to all the remaining walls of the cavity, and 
the last portions of gold introduced somewhere in 
the body of the filling, certainly not next to any wall 
of the cavity. A more thorough adaptation of the 
gold can be made to the walls of the cavity by this 
manner of arranging it than by introducing the last 
portion at one side of the cavity. There is less lia- 
bility of fracturing a frail tooth by placing the gold 
on the walls first, and terminating the introduction 
of it at or near the centre of the filling. It is the 
practice with some to introduce the gojd rather 
loosely, or without much condensing, and after being 
introduced in this manner, to condense by forcing 
into it a wedge-shaped instrument at various points, 
and filling these perforations with small rolls of gold, 
continuing to use the wedge-shaped instrument as 
long as it can be forced into the filling. This method 
is by no means as efficient as that of condensing each 
portion as it is introduced. By the latter plan the 
filling can be made uniformly dense from the surface 
to the bottom. This cannot be done by the use of the 
wedge-shaped instrument; it will compress most at its 
largest diameter, that is, at the surface of the filling. 
In no filling, even when the walls of the cavity are 
parallel, will a uniform density throughout be ob- 



192 FILLING TEETH. 

tained by perforating with the wedge-shaped instru- 
ment. The filling would be most dense at the sur- 
face, and gradually less so all the way to the bottom. 
This method is objectionable for condensing the 
fillings on the masticating surfaces of the molars ; 
for in the act of mastication the inner portion would 
yield, the surface of the filling would be crowded 
down into the cavity, and the dentine within the 
orifice become exposed, and decay be the result. In 
proximal fillings, this objection would not have the 
same force. In pressing an instrument of a wedge 
form into a filling with sufficient force to condense 
the mass, there would be great danger of breaking 
a weak wall of the cavity. The principal pressure 
is lateral, and would consequently come upon the 
side of the tooth. 

In crown cavities of the molars, where there is any 
considerable inward expansion of the cavity, that 
method of condensing would be wholly inefficient ; it 
would not render the inner portion dense enough to 
support the surface of the plug, and it would be 
forced down, and necessarily be loose. In filling the 
proximal cavities of the incisors, it is very objection- 
able on account of the great liability of breaking the 
inner and outer walls, which are usually quite thin. 

In preparing the foil for- filling, some operators 
tear off the foil in irregular pieces, and form these 



INTRODUCTION OF THE FILLING. 193 

into little halls or pellets, round and loosely rolled, 
corresponding in size with the cavity to he filled. 
These pellets are placed in the hottom. if a crown 
cavity, and at one side if a proximal cavity, and con- 
densed with a sharp-pointed instrument, attaching 
one pellet to another till the cavity is full. This 
mode is not so good as that previously referred to, 
unless the gold is in a condition to weld perfectly ; 
there is no continuous portion from the bottom to the 
orifice of the cavity, and the outer portions are liable 
to become detached. Both of these methods of 
arranging the gold are objectionable in one par- 
ticular, namely, the irregularity of the leaves or 
laminae of the foil ; these are placed in the cavity 
without regard to regularity, and the consequence is 
that, without great care, far less gold will be intro- 
duced than by some other arrangement. Much more 
difficulty is experienced in obtaining a uniform and 
equal density than when the lamime are placed 
smoothly together. 

Another method of preparing the foil is to fold it 
into from four to twelve thicknesses, then cut off 
strips in width corresponding to the diameter of the 
cavity. The strip thus prepared is introduced in the 
same manner as the roll, except that as each fold is 
inserted, it is placed smoothly against the preceding 
portion, and kept smooth and free from wrinkles. 



194 FILLING TEETH. 

By this arrangement very little force is required to 
bring the folds in perfect contact. Some care and 
skill will be necessary to bring the instrument to 
bear upon the whole surface of the fold. More gold 
can be put into a cavity in this manner than in rolls 
or pellets, unless these are used in small portions, 
and condensed thoroughly as they are put in. 



CYLINDER OR BLOCK FILLING. 

Another and in some respects far preferable 
method, is filling with cylinders or blocks. Some 
of the advantages of this method over that just 
described are the following : the filling can be intro- 
duced far more rapidly ; and the laminae, or leaves of 
foil, take a more perfect position in the cavity, and 
consequently the structure of the filling is better. 
The form of the cavity should be much the same as 
that for any other method of filling ; there should be 
some retaining point so situated that the first block, 
or blocks, can be fixed firmly in place, so that there 
will be no liability of loosening during the subsequent 
part of the process. It is important to have such an 
arrangement, as otherwise it w^ould be necessary to 
employ an instrument in the left hand to retain the 
first blocks in situation, till enough were introduced 



CYLINDER OR BLOCK FILLING. 195 

to bind the whole by pressure upon two opposite 
points in the cavity. 

Forming Bloc?cs. — For forming blocks, use any 
number of foil that may be desired, usually No. 4 or 
6, and either lay four to six sheets together, or fold 
a single sheet into that number of thicknesses ; then 
cut off from the sheets thus prepared strips about 
one-third to one-fourth wider than the depth of the 
cavity to be filled ; these are then rolled on a small 
three or four-sided broach — the three sided is better. 
This instrument should be very small — no larger, 
indeed, than is necessary for strength. Its sides 
should be perfectly smooth, and its angles sharp ; 
ordinarily it should not taper, or at least but slightly. 
For forming the conical blocks, some prefer the 
tapered broaches, but they can be as well made on 
the parallel-sided instruments. The strip being taken 
between the thumb and the index finger, is rolled on 
the broach equally, till the block or cylinder is large 
enough, when the strip is broken off. The size of 
the principal part of the blocks should be determined 
by the size of the cavity to be filled. Different sizes 
and forms will be recjuired in almost every case. 
Relatively large C34inders may be employed for the 
principal part of the filling. If the walls of the 
cavity are parallel, almost all the blocks may be 
cylindrical ; but if there is an under-dipping of one 



196 FILLING TEETH. 

or more of the walls, the blocks adjusted to that par- 
ticular part should be cone-shaped, corresponding to 
that under-dipping. A number of small graduated 
cone-shaped blocks, of different degrees of density, 
will be required for completing each filling • as the 
aperture becomes smaller, smaller blocks will be 
needed. The cone-shaped blocks are formed by gra- 
dually running the strip back from the point of the 
instrument as it is wound on ; greater or smaller 
taper can be given to it as the strip is run less or 
more rapidly back from the point. The density of 
the block can be regulated by the firmness with 
which the strip is held between the thumb and 
finger, upon w^hich it is well to have a suitable cover- 
ing, to protect the gold from the perspiration of the 
hand. There are other methods of forming blocks. 
Cylinders and blocks are prepared by foil manufac- 
turers, but they are not made in sufficient variety, 
in respect to form and density, to meet all cases ; but 
they should always be at hand, and any deficiency 
may be supplemented by the dentist. They may be 
made square, by making a great number of folds — 
fifteen to thirty — and from this cutting strips as 
before directed, and then from these heavy strips 
cutting off the blocks of the desired size, which will 
then be flat or nearly square. In one respect these 
blocks are objectionable. The edges when they have 



CYLINDER OR BLOCK FILLING. 197 

been cut off are rendered dense by the action of the 
shears, so that they do not possess the uniform den- 
sity or consistence of the rolled blocks or cylinders, 
and it is impossible to adapt them as perfectly to the 
walls of the cavity, or to one another. This objec- 
tion, however, may be obviated by cutting off the 
blocks with a very fine saw. 

Another method of forming blocks is to roll a sheet 
of No. 5 foil into a rope, and cut off from it blocks 
corresponding with the size of the cavity to be filled. 
These are liable to the same objection as those last 
mentioned, the shears hardening them when they 
are cut off. They are subject to the additional 
objection, that the folds of foil are not as regular 
as by either of the other methods. But by proper 
manipulation, with the gold prepared in this manner, 
superior fillings may be made. Another method of 
preparing blocks is by cutting a sheet of foil into two 
or three pieces, then rolling them diagonally on a steel 
wire or rod ; the size of this wire will be deter- 
mined by the required length of the blocks ; as there 
should be blocks of different lengths, the wires should 
be of different sizes, and range from No. 2 to No. 12 
of White's bur gauge plate. The size of the wire will 
be determined by the depth of the cavity. The wire 
being withdrawn, the roll is compressed to a strip. 
These strips are now rolled squarely upon a No. 20 



198 FILLING TEETH. 

steel wire, the size of the cylinder being determined 
by the size and form of the cavity to be filled. 
These may be used either in their cylindrical form 
or compressed and doubled. The cavity formed and 
the blocks prepared, the next step is their introduc- 
tion. 

Introducing the Blocks. — For placing the gold into 
the cavity, the plugging pliers are required, the 
points of which should be curved, so as to make the 
most direct approach to the cavity. The points, too, 
if properly formed, may be used to some extent for 
condensing the blocks. All things being ready, the 
cavity secured against the encroachment of moisture 
from the saliva and breath, the left hand should be 
employed to keep the rubber and the soft parts of 
the mouth in position. If there is an angle, a small 
block should be first introduced with the pliers into 
the proper position, one end upon the bottom of the 
cavity, and the other protruding from the orifice, and 
pressure then be made to consolidate it, and force it 
into its position against the wall of the cavity. This 
may be done with the pliers, or better with the 
instrument represented by Fig. 34. The part of the 
instrument brought to bear upon the gold should be 
roughened either longitudinally or transversely, so 
that a proper surface may be left for the reception of 
the succeeding portions. The largest blocks are then 



CYLINDER OR BLOCK FILLING. 199 

introduced and consolidated successively as described, 
the end of each left protruding till the cavity is 
filled ; each portion as it is introduced should be per- 
fectly condensed. The gold should be filled in faster 
at the sides of the cavity than in the centre, thus 
being disposed round the walls till it meets at a 
point opposite the place of beginning; and thus the 
gold is adapted to all the walls of the cavity before 
it is entirely filled, the last portions being introduced 
somewhere near the centre of the filling. As the 
cavity diminishes by the introduction of the gold, the 
small and more dense blocks will be required ; these 
should be forced in and condensed, by crowding the 
instrument (Fig. 36) down against the side of the 
cone. Some operators terminate the filling against 
the wall of the cavity, forcing down the blocks and 
compressing, as above, till it is full. By this method 
there is danger of fracturing the tooth, breaking 
down the wall of the cavity, where the filling is ter- 
minated. Another method is to fill up the cavity 
principally with blocks, and to put in the last part of 
the filling in the strip, filled in from the bottom to 
the orifice. The objection to this method is, that 
unless adhesive foil is employed, the portion inserted 
in the strip is liable to be displaced, and in this way 
the whole filling become destroyed. 

Another method of arranmno; this kind of filling, 



200 FILLING TEETH. 

particularly when the bottom of the cavity is irreg- 
ular, is to make a large, flat pellet, condense it firmly 
to the bottom, and set the blocks upon this for a 
foundation. By this method there is a more perfect 
adaptation of the gold to the bottom of the cavity, 
than by placing the ends of the blocks down upon an 
uneven surface. After the gold is all introduced, a 
small-pointed plugger must be passed over the entire 
surface, to consolidate the protruding portions. These 
protruding portions should be sufficient to make the 
surface, after being condensed, perfectly flush with 
the border of the cavity, for a depression here is 
fatal to a complete finish. After the condensation 
with the finely-serrated points is accomplished, then 
the blunt, smooth, polished points should be used 
with the mallet all over the surface of the filling, 
then the files, burs, stones, &c., of the various grades 
should be used to complete the finish. 

Dr. Badger described a method of filling a small 
cavity on the posterior proximal portion of a second 
molar, the third molar gone. The cavity is formed 
with a bur drill. A cylinder is then formed in the 
usual manner, and forced through a series of holes in 
a drawplate, down to the size of the bur with w^hich 
the cavity is prepared. The block is thus rendered 
quite dense. The cavity is then dried, and the block 
forced into it, which it exactly fits, protruding a little 



COHESIVE FOIL FILLING. 201 

from the orifice. This block is pierced in the centre 
with a sharp instrument, and a small dense roll 
forced into it ; all is then condensed, and finished in 
the usual manner. 

Pellets. — Pellets made bv rollino: fraarments or 
pieces of foil between the thumb and fingers are used 
by some operators, and with them they profess to 
make as good filling as by any other method. They 
are made of yarious sizes, and packed into the cavity 
with sharp-pointed or serrate-pointed instruments. 
The pieces may thus be very solidly worked to- 
gether, and a good filling made, provided the pellets 
are not too large ; they should be small enough to 
permit the point or points to work through them into 
the preceding portions. Some operators use pellets 
and crystal gold together. This may do very well 
if the cohesive property of the gold is employed ; 
but in that case, either form of the material would 
answer alone. There cannot be as much gold put in 
by pellets as by blocks or cylinders well adjusted. 

Cohesive Foil. — By this we understand that condi- 
tion of gold foil in which the leaves unite readily 
and firmly together. This property of cohesion is 
possessed in the greatest degree by properly manu- 
factured foil, immediately after annealing. Not that 
annealing imparts any new property to the gold, but 
it removes obstacles to the manifestion of a prin- 



202 FILLING TEETH. 

ciple possessed by all gold under favorable circum- 
stances. It is now about twenty years since this 
property was first employed in gold foil for filling 
teeth. To Dr. R. Arthur is due the credit of first 
directing the attention of the profession to it, as 
being available for filling teeth. He not only did 
this, but he entered most fully into the details of the 
manipulations, instruments, etc., pertaining to this 
mode of operation. Almost all recently-prepared 
gold foil possesses this property to a greater or less 
degree ; there are methods of preparing it, however, 
by which it possesses it most fully ; all recently- 
annealed foil is cohesive. If the foil is in this con- 
dition when w^e wash to use it, nothing further is 
required in the way of preparation. But if it is not 
cohesive, — as almost all foil is not, especially if it has 
been much exposed to the influence of the atmo- 
sphere, — it will require to be made so by some pro- 
cess. There are two methods, either of which will 
well accomplish the object. , 

The one most frequently employed is that of heat- 
ing the gold, either in the sheet, in the roll, or in 
fragments, over the flame of a spirit-lamp, almost or 
quite to a read heat ; if in th^ sheet, it should be laid 
upon a piece of wire gauze, and passed over the 
flame of the lamp for a moment or two ; if in the 
roll, it may be taken in the centre wath fine pliers 



COHESIVE FOIL FILLING. 203 

and passed rapidly through the flame. But if the 
gold is in the form of pellets, blocks, cylinders, or 
small pieces of any shape, it may be taken up with 
the pliers and passed rapidly through the flame of a 
spirit-lamp, till all foreign substance is burned or 
driven from it. Or it may be placed on a sheet of 
mica, which is adjusted over a flame, and then 
brought to a proper temperature. 

There are different methods of using gold in this 
condition; but in general the cavity should be formed 
about as for the other methods of filling, except that 
to retain the first piece, there should be two or three 
small pits or holes made for retaining-points in the 
most available position. The first portion of gold 
should be a little pellet ; this, forced into these re- 
taining-points, serves as a foundation for the remain- 
ing portion of the filling. Dr. Arthur's method is, 
then, to tear off fragments from the sheet, and pass it 
into the cavity without folding up, and condense it 
w^ith an instrument of finely serrated point, so that it 
not only unites by cohesion, but is worked into the 
surface of the preceding portion of gold ; and in this 
manner portion after portion is introduced and con- 
densed, until the cavity is full. The filling may be 
commenced in any part of the cavity that is most 
convenient ; in many, as in crown cavities of the 
molars, at the bottom, and filled to the orifice. In 



204 FILLING TEETH. 

putting in the gold, it should, during its introduction, 
be kept fuller about the walls of the cavity than in 
the centre ; by this means the adaptation will be most 
perfect to the walls, and there will be no liability of 
clogging in the centre. The gold may thus be built 
up to any desired extent if the filling is kept dry ; 
moisture is fatal to its cohesion. 

Others use the cohesive gold in a different man- 
ner. To Dr. Blakesley belongs the honor of first de- 
tailing the following plan : The sheet of gold may be 
folded or not at the pleasure of the operator, and then 
each sheet cut into from two to six strips, and each 
of these formed into a loose roll between the thumb 
and fingers. These should now be passed through 
the flame, as already described, then cut into little 
blocks or pellets of various sizes ; these to be regu- 
lated by the size of the roll and the cavity to be 
filled. For the introduction of the gold thus pre- 
pared, about three sizes of instruments are required, 
those having finely serrated points being preferable. 
As to the sizes of these points. Dr. Blakesley re- 
marks, " They should just enter respectively Nos. 
22, 24, and 26 of the wire-gauge." A larger than 
either of these, however, is desirable for many cases. 
As before, the filling may be commenced at the bot- 
tom of a cavity, or at one side, if desirable, with a 
pellet sufficiently large to be set firmly into the re- 



THE MALLET. 205 

taining pits. Then take up the small pellets or 
blocks upon the point of the plugging instrument, 
and place them exactly in the desired position, and 
consolidate them thorotighly. building tip next to the 
wall all around higher than the centre, with the 
smaller pieces, filling up the little corners and inter- 
stices, for which manipulation the smaller points will 
be required. The gold is then packed in till the 
cavity is full, when it is finished as usual. Another 
method is to tear off fragments from the sheet, and 
roll these tip into round pellets, and fill with these, 
with the same instruments and upon the same prin- 
ciple as above described. But by this method it is 
difficult to make a perfect filling ; the gold is liable 
to clog in the cavity, and fail in adaptation. 

Cohesive gold must be consolidated as it is intro- 
duced ; for if a cavitv is fnll. it is very difficult then 
to condense it more, even though the consolidation is 
but partial : and the same is true to some extent of 
non-cohesive foil. 

THE MALLET. 

In the year l!^60. Dr. W. 11. Atkinson intro- 
duced to the dental profession the mallet for the 
purpose of condensing gold in filling teeth. This 
effected quite a change in the theory and practice of 



206 FILLING TEETH. 

this part of the work. Prior to this period it was 
accomplished entirely by the pressure or force exerted 
by the hand. There was very considerable diversity 
of opinion as to the best mode of this manipulation, 
some maintaining that great force is always required 
to make a filling sufficiently dense, — assuming that 
it is better to use comparatively large points, great 
pressure and rapid execution, thus securing the 
utmost economy of time, both to the operator and 
patient. Others entertain the opinion that with 
smaller points, less pressure, and greater time, a 
more definite and satisfactory result is attained. 

Notwithstanding the diversity of opinion and prac- 
tice upon this subject, w^e would suggest that young 
operators, at least, should bear in mind that in so 
important a matter as filling teeth, efficiency should 
never be sacrificed to rapidity. 

This method is especially applicable and efiective 
for the condensation of cohesive gold, and indeed 
gold in any form, when the aim is to condense each 
portion as it is introduced. A more thorough con- 
densation is made by the use of the mallet than is 
possible by the hand alone ; greater precision of 
manipulation is attainable ; it is easier for the ope- 
rator, and usually less unpleasant to the patient. 

The character of the results in the use of this 
instrument depends much upon the skill of the 



THE :^[ALLET. 207 

assistant. It requires tinie. care and patience to 
familiarize an assistant with the use of the mal- 
let. The plugger shoukl be held firmly in position 
by the operator, and receive the stroke squarely 
upon the end ; it should be a sharp, springing tap. 
Very much depends upon the character of the blow; 
a dead, heavy stroke will not unite the gold as it 
should be. It is important that the assistant be able 
to foUow the indications of the operator without loss 
of time. Many assistants are disposed to give time 
strokes instead of following indications, which are 
not admissible except in very simple cases. 

In order to avoid the employment of an assistant, 
and to place the strokes of the instrument more under 
the control of the operator, various forms of auto- 
matic maUet pluggers have been invented and con- 
structed. Two or three principles embrace the whole, 
though many different forms have been made. Those 
operated by the action of spiral springs have been 
the more common; the objection to almost all of 



these is, that the stroke lacks the desired elasticity. 
This class of instruments is represented in general 
aspect by Fig. 81. 



208 



FILLING TEETH. 



This instrument was invented by Dr. I. A. Sal- 
mon, and is one of the best of this form ; it operates 
well in the hands of those who become familiar 
with it. 

Another form of mallet plugger is represented in 
Fig. 82, in which the blow is communicated by a 

spring of another form, 
ilil and of such an ar- 

rangement as to give 
an elastic stroke. This 
instrument was invented 
and made by Dr. W. Gr. 
Redman. It would be 
objectionable in the hands of some, because 
of its size, weight and form. Use and 
custom will remove great apparent, and 
even real, difficulties. 

Both of these instruments are less under 
the control of the operator, in respect to 
the force of the blow, than they should be. 
It is true that in both the force can be 
regulated to the most minute degree, be- 
tween a very light and a very strong stroke; 
it cannot be done, however, without giving 
special attention to that particular, which 
necessitates an arrest of the operation of 
the instrument. 




THE MALLET. 209 

An instrument is made by Dr. S. B. Palmer, in 
which the force of the blow is jjlaced completely under 
the control of the operator while it is being used. 
The operation of this instrument is perhaps less 
objectionable, in respect to the character of the 
stroke, and its control by the operator, than any 
other as yet employed. Any of these instruments 
are valuable in the hands of those who become 
familiar with them. 

During the last few years efforts have been 
made to operate the mallet by various motors. The 
first attempt in this direction was by Dr. G. W. 
Bonwell, by the application of galvano-electricity. 
The first machines were very crude and unsatisfac- 
tory ; but b}^ improvements made from time to time, 
the instrument is quite efficient in the hands of those 
familiar with it. 

A mallet has been invented and constructed by 
Professor T. L. Buckingham, designed to be attached 
to and operated by the dental engine. It is more 
under the immediate control of the operator than 
most of the automatic mallets in use. This is highly 
prized by many. The pneumatic mallet was devised 
by Dr. W. H. Jackson. This consists of an ingenious 
and yet simple application of air as a motor. For a 
description of each of these, with illustrations, see 
Appendix of this work, Sec. C. 



210 FILLING TEETH. 

CRYSTAL OR SPONGE GOLD. 

The form of the cavity for crystal gold filling 
should be much the same as that described for other 
fillings, except that the same care is not necessary 
for special retaining-points ; for the first portion of 
good crystal gold that is introduced into the cavity 
will attach to the walls without any such provision. 
Such a form should be given, however, as to secure 
the first piece firmly in place. The gold should be 
cut or broken into pieces corresponding in size to the 
cavity, so that they will enter freely into it. 

The filling may be commenced upon the bottom of 
the cavity, or upon one of its sides ; such a point 
always being selected as will most effectually retain 
the gold in place. The pluggers should be of vari- 
ous sizes — the first one as large as can be used freely 
in the cavity, and smaller ones for condensing more 
thoroughly ; and all should be serrated. The blocks 
may be taken up on the point of the plugger, or 
perhaps better with the pliers, and passed to the 
proper position in the cavity, and there condensed. 
The sharp serrated point leaves the surface in good 
condition for the reception of the next piece. The 
gold should be packed to the walls of the cavity a 
little in advance of the centre, so that its adaptation 
may be more complete. In this manner the filling is 



CRYSTAL OR SPONGE GOLD. 211 

built up as much as is desirable, if it is kept dry. — 
and unless it is, cohesion is very much diminishedj 
or lost altos^ether. 

The gold, after it is cut up, is ]Dassed through the 
flame of a spirit lamp, to anneal it, and dispel all 
foreign substances. It should in no case be brought 
above a perceptible red heat, and usually not to that 
point ; it should be done carefully, so as not to fuse 
any of the particles, as that ^vould impair their 
facility of cohesion in this process. Small portions 
are often required to fill up small interstices, or 
notches. 

In crown cavities, the filling should begin at the 
bottom ; in proximal cavities, at the cervical wall. 
By introducing the gold in this manner, the pressure 
is made on a line with the axis of the tooth, which is 
an important consideration. The surface of the filling 
should be made to conform to that of the lost portion 
of the tooth ; this can always be done except where 
the tooth is largely broken away, and even then 
very much may be accomplished in many cases to 
restore the lost form ; that will depend, however, 
upon the method of using the gold, and the security 
of the attachment for it. In crown fillings of the 
molars and bicuspids, the antagonism of the teeth 
must be regarded ; they should be formed for the 
reception of the cusps of the opposing tooth. Proxi- 



212 FILLING TEETH. 

mal fillings should usually be convex ; yet many 
good fillings of this class are made with a surface 
perfectly plain with the borders of the cavity. The 
borders of the filling, however, are better protected 
when it is somewhat convex. 

Crystal gold, of perfect character, presents to the 
walls of the cavity a surface better calculated to be 
retained than foil in any of its forms ; though cohe- 
sive foil possesses this advantage to a greater extent 
than foil in any other condition. The points and 
edges of the crystals are brought in contact with the 
walls, and take a firmer hold upon the dentine. 

In forming crystal gold into a solid mass, two 
principles are operative : cohesion acts upon it as 
potentially as upon gold in any other form, and, in 
addition, there is the interlacing, or locking, of the 
crystals with one another; so that a more perfect 
union of the different portions of which a filling is 
composed is obtained with crystal gold than with 
foil. Yet good cohesive foil, when properly manipu- 
lated, attains almost the same condition. 

It is important to keep the gold perfectly free from 
moisture while being introduced and consolidated ; 
for moisture instantly destroys its cohesive property. 
And the more complete the exclusion of moisture 
from the cavity during the process, the better for 
the success of the operation. The surface of every 



CRYSTAL OR SPONGE GOLD. 



2n 



filling should be consolidated for finishing before 
it is allowed to become moist, for if it becomes 
saturated with moisture before consolidation, it is 
impossible to make a perfect finish. There should 
always be gold enough superadded to insure this ; 
and the consolidation of the surface should be efi'ected 
with a burnisher of the proper form, used with the 
mallet, consolidating the entire surface as thoroughly 



ci e> O 




^ 



u 



and smoothly as possible, exercising great care about 
the borders of the filling. Fig. 83 represents the 
forms of the burnishers suitable for almost all cases. 



FINISHING FILLINGS. 



The method of finishing a filling, and the manipu- 
lation required, will depend somewhat on its locality. 
When the filling has been thoroughly consolidated 



214 FILLING TEETH. 

over all the surface, and especially all round its 
border, the file should be applied to dress off any 
projecting portion, and render it smooth. In con- 
solidating the surface, an instrument should be used 
that would not pit it, and the file or finishing bur 
should remove all indentations. The work of these, 
however, should be but partially performed at first, 
and the surface burnished again. To obtain the most 
perfect finish, the surface should be brought to a 
uniform consistence ; and this condition cannot be 
reached by the use of sharp-pointed instruments, nor 
fully by that of the blunt plugger at the first effort, 
but by the alternate use of the file, the blunt con- 
denser, with the mallet, and the burnisher. A coarse 
file or bur should be employed in this part of the 
process ; but when the filling is dressed sufficiently, 
and in good condition, the fine file should be used 
alternately with the burnisher, till a perfectly uni- 
form surface is obtained. In all cases, after the file 
has been applied, the plug should be washed off with 
a brush, to remove all detached pieces of gold, before 
the burnisher is put upon it ; and after the fine file 
and burnisher, the Scotch or Arkansas-stone, or 
corundum slips of the proper form, used with the 
port-polisher, or very fine pumice, should be employed 
to remove the file-marks. The pumice may be applied 
with water on a strip of chamois skin, a piece of 



FINISHING FILLINGS. 215 

linen tape, or a stick of soft wood — the latter being 
the most convenient, as it can be used with one 
hand — shaped to suit any place or position. Emery 
cloth of every requisite grade of fineness is now ob- 
tainable ; this may be cut into strips of any desired 
width. It is very efficient for finishing all fillings in 
the proximate portions of the teeth. 

After the stone or the pumice has accomplished its 
work, and the filling has been thoroughly washed, a 
fine burnisher, with a solution of castile soap, is em- 
ployed to give the finish. The burnisher should be 
of the best cast vsteel, and of high temper and fine 
polish. Considerable skill is requisite to give the best 
effect with the burnisher ; it should pass smoothly 
and gently over the surface, throughout its whole 
extent, and in parallel lines, with a pressure neither 
too light nor too heavy. It should also be applied 
very thoroughly upon any portion of the tooth about 
the border of the filling that may have been cut by 
the file or any other instrument. Indeed, quite as 
much, if not more, care should be exercised upon 
this as upon the plug itself: it should be polished as 
smooth as the enamel, if possible, for the more nearly 
perfect it is in this respect, the better will it resist 
the action of the deleterious agents. 

This method of finishing gives to the filling a per- 
fect metallic lustre, which, under some circumstances, 



216 FILLING TEETH. 

is objectionable. T\yo other methods are in use : 
After the burnisher has been applied, as above, the 
buffer tape, with rouge, may be employed, by passing 
it rapidly over the filling, till the metallic lustre is 
destroyed, or deadened, so as not to reflect the light 
as before, thus leaving a very desirable finish ; and 
the other method is, to stipple over the surface of 
the burnished filling with the end of a piece of hard 
wood, — sandal wood is recommended, — charged with 
finely-pulverized pumice. This gives a beautiful, 
velvet-like surface, and is applicable to fillings in the 
anterioi^ portion of the mouth, where they are ex- 
posed to view. Rotten-stone, applied either with 
the buff or with hard wood, imparts a finish which, 
although a little different, is equal to any of the 
others. 

For finishing, some operators prefer to cut and 
polish, instead of filing and burnishing. But neither 
so good nor so fine a finish can be effected in this 
way, and it is probable that economy of time and 
labor, especially the latter, suggested the method. 
The introduction and use of the corundum cones and 
disks, cones of Hindustan and Scotch stone, and the 
wood cones and buffs (represented on pp. 115, 116), 
all to be used with the dental engine, greatly facili- 
tate the work of finishing, and perhaps accomplish it 
better ; but great care should always be exercised in 



FINISHING FILLINGS. 217 

the use of these implements. In all cases the filling 
should have a distinct and definite margin ; the gold 
should be trimmed off quite up to the border of the 
cavity, by passing round it a small sharp instrument, 
so as to detect and pare down any portion that might 
overlap the tooth ; for if overlapping portions are 
permitted to remain, foreign substances will lodge 
beneath, and induce decay. Neglect in this particu- 
lar has occasioned the loss of thousands of teeth that 
otherwise might have been saved. This direction 
does not apply to those cases elsewhere mentioned, 
in which it is recommended to form a thick, firm, 
overlapping portion, for the protection of a thin 
friable border. 

The subject of finishing is almost entirely over- 
looked by very many operators, but by the neat and 
skillful it is esteemed of sufficient importance to de- 
mand as great labor and pains as any other part of 
the work. 



CHAPTER VII. 

CLASSIFICATION OF DECAYED CAVITIES. 

The following classification of decayed cavities in 
the teeth, though from the very nature of the suhject 
imperfect, will be found sufficiently accurate to aid 
the dental student and the practitioner. It is based 
primarily on the position of the cavities, and second- 
arily on the extent of the decay, — the classes having 
reference to the former and the modifications to the 
latter. The classes are numbered according to the 
accessibility of the cavities, beginning with those 
most easily approached and operated upon, and the 
modifications according to the extent of the decay, 
beginning with the smallest and simplest in form. 

First Class. — Simple central crown cavities in the 
molars and bicuspids. 

l^i^ Mod. — Extension of the decay along one or 
more fissures or depressions. 

2d Mod. — Two decays in close proximity on the 
same crown, which may be formed into one cavity 
for filling. 

Second Class. — Cavities in the buccal and palatal 



CLASSIFICATION OF DECAYED CAVITIES. 219 

surfaces of the molars and bicuspids, and in the labial 
and palatal surfaces of the canines and incisors. 

1st Mod. — Extension of the decay beneath the 
margin of the gums. 

2d 3fod. — Extension of the decay so as to involve 
a portion of the crown surface. 

Third Class. — xVnterior proximal cavities of the 
bicuspids and molars. 

1st Jlod. — Extension of the decay toward the neck 
of the tooth, beyond the termination of the enamel. 

2d 3Iod. — Extension of the decay so as to involve 
a portion of the grinding or crown surface. 

Fourth Class. — Proximal cavities of the incisors 
and canines. 

1st 3Iod. — Palatal wall of the cavity broken away. 

2d 3Iod. — Labial wall broken away. 

od Mod. — The cavity at the point of the tooth, 
terminating at the surface. 

ith 3Iod. — The borders of the cavity very thin, 
and the lateral walls inclining to the centre. 

Fifth Class. — Posterior proximal cavities of the 
molars and bicuspids. 

Modifications same as those of third class. 

Modifications common to all the classes : — 1st. Su- 
perficial cavity arid a large orifice. 2d. Deep cavity 
and a small orifice. 

Modification common to classes three, four, and 



220 CLASSIFICATION OF DECAYED CAVITIES. 

five : — Transverse extension of the decay round one 
or more angles of the tooth, under the termination of 
the enamel. 



FILLING BY CLASSES AND MODIFICATIONS. 

First Class. — Central cavities of the molars and 
bicuspids. These decays always begin in the depres- 
sions on the masticatory surfaces, v^hich are vulner- 
able points, the enamel-membrane folding together 
here, and often being imperfectly united, so that an 
opening is left partially or wholy through it to the 
dentine ; besides, these indentations afford lodgment 
to foreign substances, which may be forced into them 
in the process of mastication, and there retained till, 
becoming vitiated, they produce decay. 

Examine carefully the extent and the nature of 
the decay, and the form of the cavity, which, of 
course, greatly varies. In some cases the cavity is 
found with a small diameter and a comparatively 
great depth, the diameter at the orifice being the 
same as within; in others, with a diameter larger 
at the orifice, as occurs in cases in which a consider- 
able portion of the enamel at the depressions on the 
crown is imperfect. In the majority of instances, 
however, the diameter of the cavity is much larger 
within than at the orifice. Sometimes the decay is 



FILLING BY CLASSES A^B MODIFICATIONS. 221 

found to burrow directly beneath the enamel more 
rapidly than in any other direction, as where there is 
an imperfect union between the enamel and the den- 
tine. In other instances, the cavity seems to expand 
uniformly as it extends into the tooth. 

The manner of opening up and preparing the 
cavity for filling will depend somewhat on the form 
given to it by the decay. If it is larger at the orifice 
than within, there will be little or no cutting of the 
cavity about the orifice necessary, except to make it 
even and smooth ; and its preparation will consist in 
an entire removal of the decay, and such shaping 
of the interior as will insure retention of the fiUino;. 
This may be effected either by enlarging the cavity 
within, till its walls are parallel with each other, or, 
if these are left converging, by forming pits or grooves 
upon them at proper points. Converging walls pre- 
sent one or two advantages, which will be hereafter 
considered. Usually, where the decay has formed a 
cavity of nearly uniform diameter from the orifice to 
the bottom, about all the preparation for filling that 
is requisite is a thorough removal of the decay. In 
cases in which the decay burrows under the enamel, 
the projecting portions are to be cut down, either with 
a bur drill or, what is generally better, a heavy 
cutting instrument. In most instances it is best to 
cut away the enamel as far as the decay has extended 



2*22 CLASSIFICATION OF DECAYED CAVITIES. 

beneath it, since it is difficult to make a perfect fill- 
ing under a projecting portion. In some cases, how- 
ever, where the enamel is thick and firm, it is admis- 
sible to leave a slight projection, so as to form a 
shallow groove. 

The walls of these cavities will be of various in- 
clinations. If they converge, pits or grooves may be 
required upon them for retaining-points, especially if 
the enamel is cut away at the orifice to the solid 
dentine. If, however, the walls, or -two opposite 
walls, are parallel, or but slightly divergent, these 
special retaining-points will not be requisite, except 
for the reception of the first pieces of gold. Small 
cavities of this class may be opened up and formed 
principally with the bur and drill ; and even in large 
cavities much of the work of opening, excavating, 
and forming may be done with burs of the proper 
size and form, used with the engine. Thus the 
orifices of the small cavities would be round, while 
those of the large would be of various forms, deter- 
mined by the direction of the decay, as, round, 
square, triangular, elliptical, parallelogramic. Cavi- 
ties should not be formed much larger within than at 
their orifices, unless the filling can be consolidated so 
perfectly that it will not yield in the least under the 
greatest pressure of mastication j for, if there is 
yielding in such cases under direct pressure, the fill- 



FILLING BY CLASSES AND MODIFICATIONS. 223 

ing being forced into a larger part of the cavity, with- 
draws from the walls, leaving an interval correspond- 
ing with the depression it has undergone ; and thus 
fluids would be admitted between the walls and the 
filling, and the purpose for which this was inserted 
would be entirely defeated. 

Many operators ream the orifices of all the small 
and medium-sized cavities of this class, in order 
thereby to make a better finish to the border of the 
filling. Some operators prefer in all cases to remove 
the angle formed by the wall of the cavity and the 
surface of the tooth about the orifice, giving a rounded 
form to the border of the orifice, the object being to 
avoid fracturing or comminuting the edge of the 
enamel or dentine about the cavity. All acute angles 
in these cavities, especially if they extend to the 
orifice, should be obliterated, since it is impossible to 
fill them perfectly. This obliteration can be effected 
with a miniature chisel, or with the appropriate exca- 
vator, or, perhaps better still, with the bur of the 
proper size and shape. 

After the formation of the cavity, the next particu- 
lar is so to arrange as entirely to exclude moisture, 
whether from the saliva or from the breath. If pro- 
vision was not made at the beginning of the opera- 
tion for the exclusion of moisture, it cannot now be 
longer delayed. As already intimated elsewdiere, this 



224 CLASSIFICATION OF DECAYED CAVITIES. 

is accomplished by the use of the rubber dam. The 
general method of its application has been considered, 
yet a few suggestions in reference to it in an opera- 
tion upon this class of cavities may be of value, 
especially to the beginner. 

The precise method of procedure at this point will 
be modified by the size of the mouth, and the ability 
or will of the patient to control it. For a cavity of 
this class, it will, in nearly all cases, where the 
mouth is favorable in the particulars just referred to, 
be quite sufficient to embrace with the rubber only 
the tooth to be operated upon, and this whether it be 
in the superior or inferior jaw. 

If the tooth in question stands in firm contact with 
its neighbors, passing the rubber between the teeth 
may be quite unnecessary, but let it be drawn over the 
crown, and down or up, as the case may be, upon the 
buccal and lingual sides to the margin of the gum, then 
place on the clamp, which will hold all in position. 

This properly done, all moisture wdll be efi'ectually 
excluded ; success in this, however, depends some- 
what on the accurate adaptation of the clamp to the 
tooth. If the rubber can be readily passed between 
this and either or both of the contiguous teeth, it is 
well to do so, thus making the work more secure, if 
the clamp should be defective in adaptation. When 
the mouth is small, or not properly controlled. 



FILLING BY CLASSES AND MODIFICATIONS. 225 

greater precaution will be requisite ; in such cases 
the rubber should always be passed between the 
teeth, and in some instances over one or two neidi- 
boring teeth, in order that the operation may not be 
embarrassed by encroachment of the rubber. But in 
no case should it be placed upon more teeth than is 
necessary to meet the demands of the case. The 
free border of the rubber should now have the bands 
and weights applied, so that the utmost freedom 
of approach may be made to the point of opera- 
tion. The cavity should be thoroughly dried with 
bibulous paper and the Avarm air blow-pipe, when a 
minute examination of the cavity, at every point and 
in every particular, should be made, and any imper- 
fections remedied. And now, with the automatic 
saliva extractor in place and operating, the work of 
introducing the filling may proceed. 

In some small simple cavities of this class, in the 
upper teeth, with conditions favorable, and but a short 
time required for introducing the filling, the following 
arrangement may serve the purpose : Wipe dry the 
mucous membrane about the mouth of the duct of 
Steno ; lay directly upon this a piece of heavy blotting 
paper, or a roll of bibulous paper ; then take a napkin 
folded cornerwise, lolace the end of it upon the paper, 
between the cheek and the gum, passing it back of the 
tooth to be operated upon, along the palatal surfaces 



226 CLASSIFICATION OF DECAYED CAVITIES. 

of the teeth and the gums to the anterior part of the 
mouth, and letting a fold of it extend down from 
this, and out over the inferior front teeth and the 
lip, so as to protect the tooth froDi the breath, and 
catch any fragments of gold that may drop from the 
instrument. The napkin and paper, thus arranged, are 
to be kept in their place by the fingers of the left 
hand of the operator ; and if the mouth of the duct 
is kept closed by the paper, a complete exclusion of 
moisture is secured, so far as that source is con- 
cerned. In some cases pressure of the fingers on the 
napkin over the duct is necessary ; in others, the 
paper adheres to the mucous membrane, and effectu- 
ally prevents the egress of saliva. The cavity should 
now be dried by the method heretofore described, 
and it is ready for the filling. 

In the absence of the automatic saliva extractor, 
the saliva pump represented in Figure 84 will serve 

Fig. 84. 




a valuable purpose, though it does not completely 
fulfill the requirements. 

An instrument invented by Dr. W. H. Dibble, 
called " Dibble's Saliva Pump," performs the work of 



FILLING BY CLASSES AND MODIFICATIONS. 



9-27 



both the saliva pump and 
tongue holder. As a saliva 
pump it is much superior 
to the instrument repre- 
sented in Fig. 84, which 
is in common use. 

It is operated by the 
patient, and removes the 
saliva immediately after 
it enters the mouth, and 
may be in constant action, 
without the slightest in 
terruption of the operati( ii 
of filling; the saliva pass 
into a reservoir, and i 
perfectly enclosed till t] 
operation, however pi 
tracted, is completed. 

That part of the instru- 
^ ment designed to hold the 
tongue and the buccal sur- 
face from the tooth to be 
operated upon, and to hold 
the jaws apart, is of a very 
excellent form, and accom- 
plishes its work well. It 
is in three parts, one 




228 CLASSIFICATION OP DECAYED CAVITIES. 

adapted to each side of the mouth — in these the 
saliva is taken up by the instrument opposite the 
lingual surface of the second inferior molar — and 
one for the front, with a compressor passing on 
to the tongue and holding it firmly down, and the 
pump-tube takes the saliva from the immediate 
vicinity of the sublingual ducts. 

This latter part of the instrument is the device of 
Dr. B. F. Arrington. The instrument is well repre- 
sented in Fig. 85. That part of this instrument de- 
signed to hold down the tongue is rendered unneces- 
sary by the use of the rubber dam. 

It is often the case that the finger is too short to 
reach a desired point, to hold down a napkin or 
paper, or hold away the soft parts, or is so large as 
to fill the space inconveniently, obstructing the view 
of the operation. To overcome both of these difficul- 

.Fig. ■ 




ties, an extension thimble is used ; it*may be made 
of silver or rubber, though better of the former. In 
addition to the uses mentioned, it may, by having a 



FILLING BY CLASSES AND MODIFICATIONS. 229 

fine steel point, be made to serve as a holder to 
aid in introducing fillings. (Fig. 86.) 

Various appliances have been used for holding 
away the cheek, keeping down the tongue, and re- 




taining the jaws apart. An instrument for this pur- 
pose is shown in Fig. 87. 

Filling tuith Foil. — If non-cohesive gold is employed, 
it should be formed into blocks, by cutting from four 
to eight thicknesses into strips one fourth wider than 
the cavity is deep, and rolling them on a broach 
suitable for the purpose, into cylindrical blocks cor- 
responding in size with the cavity to be filled, and 
varying not only in size, but in form and density. 
The blocks first to be introduced should be largest, 
followed by those diminishing in size, the last por- 
tions being small, dense, conical rolls. Where there 
is an inward or outward inclination of the walls of 
the cavity, the first blocks should be cone-shaped. 
For introducing the blocks, the plugging pliers will 



230 CLASSIFICATION OF DECAYED CAVITIES. 

be required. The first block is taken up with this 
instrument and placed against the posterior wall of 
the cavity, with one end on the bottom and the other 
protruding from the orifice, and there compressed 
firmly to its place with the appropriate condensing 
instrument ; and, unless there is some special retain- 
ing point, it may be necessary to hold it in its posi- 
tion with a second instrument, till the next portion 
is added. As the successive blocks are introduced, 
each is to be thoroughly consolidated, so as to be 
immovable. The filling is to proceed from the pos- 
terior wall to the centre. After the cavity has thus 
been filled to the centre, commence in the same 
manner at the anterior wall, filling from thence 
toward the centre, and condensing the last blocks 
by forcing in at their side a small sharp-pointed 
instrument ; the final portion introduced will be the 
small, dense, conical roll already mentioned. The 
gold being all introduced, a smooth-pointed instru- 
ment or burnisher condenses the projecting portion 
of the filling till it is perfectly solid, when it is 
finished with a file, stone and burnisher in the 
manner already described. The particular shape of 
the surface of the filling will be suggested by the 
form of the antagonizing tooth. Usually the surface of 
these fillings should be slightly concave; in some cases 
the occlusion of the teeth is such as to require very 



FILLING BY CLASSES AND MODIFICATIONS. 231 

considerable concavity ; this, lioweA^er, should only be 
sufficient to accommodate the closure of the teeth. 

For dressing down the burs, corundum cones, 
Scotch stone and buff cones used with the engine, 
represented by Figs. 28 and 29, will serve the pur- 
pose most fully. 

Cohesive Foil. — For filling these cavities with co- 
hesive foil, definite retaining-points should be formed 
in them, or the bottom of the cavity of such a form 
as to retain firmly in position the first pieces of gold 
introduced. The gold, prepared in the manner 
already described, is taken up with a serrate-pointed 
plugger or plugging pliers, introduced into the re- 
taining point or points, and there fixed; it is then 
built across from one to the other, and over the floor 
of the cavity till this is completely covered, and then 
up from the bottom to the orifice. When a portion 
of gold is taken on the point of the instrument, the 
precise spot at which to deposit it should be selected, 
and there it should be placed, and, by the first 
pressure of the instrument, fixed immovably ; a 
few subsequent strokes of the instrument, near the 
first point of attachment, will be required. These 
strokes should be close, because if the instrument is 
lifted up and pressed upon the piece at a distance 
from the first point of contact, the attachment is 
liable to be broken. The character of the gold, and 



232 CLASSIFICATION OF DECAYED CAVITIES. 

the condition of the receiving surface will govern to 
some extent the precise method of manipulation. 
Very much depends upon keeping the surface in 
a good condition for the reception of the gold to be 
added. The hest receiving surface is obtained by 
having the condensing instrument sharp and in good 
condition, and then in using it, let there be a little 
space between its impressions — the surface not 
stamped completely over by the condensing instru- 
ment. In constructing the filling, we consider it 
preferable to keep it built up a little higher all 
around next the walls than at the centre, for the 
reason that a more complete adaptation of the gold 
can thus be made than by any other plan. Some, 
however, advocate the opposite practice; that is, of 
keeping the filling higher in the centre than at the 
walls, and thus forming an angular space into which 
to crowd the gold ; because the gold is thus kept in 
more thorough contact with the walls of the cavity ; 
and it is objected that, to add and consolidate the 
gold to the centre, while the edges are left higher, 
tends to draw them from the walls. This objection, 
however, has no force, if the gold is thoroughly con- 
solidated as it is introduced. 

The cavity is thus filled up, consolidated, and 
finished in the usual manner. In adding the last 
portions of gold, great care should be taken to make 



FILLING BY CLASSES AND MODIFICATIONS. 233 

a perfect border to the filling. Crystal gold may be 
very advantageously used as a foundation for cobe- 
sive foil fillings, as it will retain its position perfectly 
in a cavity, where foil will not. 

Crystal Gold. — The method of filling this class of 
cavities with crystal gold is very simple. The mate- 
rial should be annealed just before its use, and then 
cut or broken into blocks corresponding wdth the size 
of the cavity to be filled ; they may be used as large 
as will freely enter the cavity; many small pieces 
will be required to fill up interstices or angles. The 
filling may be commenced at the bottom of the cavity, 
and built up from that to the orifice, the same plan 
being foUow^ed in adapting it to the walls as with co- 
hesive foil, the pieces being passed into the cavity 
with either the plugging pliers or a condensing in- 
strument. Each piece should be well consolidated 
before another is added. For condensing the filling 
next to the walls, a small wedge-shaped instrument is 
valuable. In all cases where there is a divergence 
of the anterior wall, much care is required in order to 
make a perfect filling ; and too much care cannot be 
exercised in perfecting the filling round the border of 
the cavity. In condensing cohesive foil or crystal 
gold, the force may be applied almost exclusively in 
a line with the axis of the tooth ; and this is always 
preferable to lateral pressure. 



234 CLASSIFICATION OF DECAYED CAVITIES. 

1st Mod. — Extension of decay along one or more 
of the crown fissures. In a case of this kind, the 
central cavity is first to be opened and excavated, 
according to the principles already announced. Decay 
in the fissures is in some cases an extension of this 
central decay, and at the point of its termination 
there will be found an acute angle ; but in others, it 
will be the effect of an equal attack all along the 
fissure, or of an extension from some other point 
than the central cavity. This modification of decay 
may terminate either in an acute angle or in an 
expansion. 

These decayed fissures should be opened up by 
cutting away any projecting portion of enamel, and 
the cavities formed with a small chisel-shaped instru- 
ment, beginning at the juncture of the fissure with 
the main cavity, and cutting down to the bottom of 
the decay in the manner of a mortise, thus cutting 
out the entire fissure and the acute angle at its ter- 
mination — the latter an important consideration. In 
case there is a very considerable expansion of decay 
at the termination of the fissure, the bur drill may be 
introduced into it, and the rest of the fissure cut out, 
as the form of the cavity may indicate. In exca- 
vating and forming these fissures, the burs made for 
the purpose (shown in Fig. 22), and used with the 
engine, give greater facility and rapidity of execution 



FILLING BY CLASSES AND MODIFICATIONS. 235 

than by the method just described, and with care, 
equally as definite results. 

If blocks are used to fill these cavities, they should 
be set in and compressed against the end of the fis- 
sure, protruding from it sufficiently to admit of a 
proper finish ; and block after block added, till the 
fissure is filled up to the main cavity. Where there 
are two or three of these decayed fissures in one 
tooth, it may be quite as much as can be done at 
one sitting to fill them, the main cavity being left 
for another time. In such cases, the filling introduced 
at the first sitting should then be consolidated and 
burnished, so that it may not absorb moisture while 
the main cavity is filled, as already described. Much 
care should be exercised to prevent the gold from 
overlapping the enamel at the sides of these fissures. 
In filling this modification with crystal gold or an- 
nealed foil, it is better to begin at the bottom of the 
cavity and build np to the orifice, first completing 
the fissure, as we have already described, and after- 
ward the main cavity. 

^d Mod. — Two cavities on the same crown in close 
proximity. The thickness of the portion of tooth in- 
tervening between two cavities on the grinding sur- 
face of the same crown is determined by the location 
and extent of the decay and by the form of the 
cavities ; and these two conditions will suggest the 



236 CLASSIFICATION OF DECAYED CAVITIES. 

method of operation. If this intervening portion is 
thin throughout, and devoid of vitality, it should be 
cut away, and the two cavities formed into one ; but 
if it is thick within, though it may be thin at the 
surface, the cavities should be filled separately. In 
some cases it is proper to leave a part of it standing, 
as a sort of ridge between the cavities, though not as 
a definite partition ; in which case the filling would be 
commenced as in two cavities, and finished as in one. 
In no case, however, when the tooth is living, should 
this intervening portion remain, if its vitality is gone. 
The details of the process of filling crown cavities 
have already been indicated. 

Second Class. — Buccal and palatal cavities of the 
molars and bicuspids, and labial and palatal cavities 
of the canines and incisors. In the molars, this class 
of decay begins either at the margin of the gum, in 
the form of a transverse groove, or along the vertical 
depression on the buccal surface of the tooth, or at 
its termination. These groove-like decays, extending 
along the side of the tooth at or near the margin of 
the gum, are ordinarily not very deep ; but they 
burrow considerably under the enamel, particularly 
at the side next the grinding surface. In preparing 
these cavities, the projecting portion of the enamel 
must be mostly cut away, leaving them but slightly 
larger within than at the orifice. These grooves, at 



FILLING BY CLASSES AND MODIFICATIONS. 237 

their ends, are shallow ; but in their preparation for 
filling, they should be cut as deep at the ends as 
elsewhere, and when the main part of the cavity is 
comparatively shallow, deeper. Much difficulty is 
often experienced in protecting these cavities from 
moisture while being filled. The rubber dam, when 
well applied, accomplishes the object better than any 
other appliance ; it is in such cases invaluable. 

The method of introducing gold in the form of 
blocks into these cavities, is to set in the first block 
at the posterior part of the cavity, and consolidate it, 
and so one block after, another till the cavity is 
nearly full; and then proceed in like manner with 
the anterior end, back toward the middle, the blocks, 
of course, being permitted to protrude sufficiently for 
the purposes of a finish. For filling with crystal 
gold or cohesive foil, the method is, to form pits at 
the end of the groove, into which the gold is consoli- 
dated, and built across from one to the other, and 
then up from the bottom to the orifice, when it is 
finished as usual. Care is requisite to prevent the 
gold from overlapping the tooth outside of the cavity. 
Any projection of the filling, especially beyond the 
margin of the cervical wall of the cavity, is very ob- 
jectionable ; it would afford a lodgment for extra- 
neous substances, the tendency of which is to pro- 
duce irritation and decay. 



238 CLASSIFICATION OF DECAYED CAVITIES. 

Cavities of this class, which are formed in the de- 
pressions of the buccal portions of the teeth, are 
more easily filled. Often a simple round cavity is 
formed at the coronal termination of this depression, 
which may be entirely prepared with a bur drill. 
The method of filling these cavities will be readily 
inferred from the remarks before made. If, however, 
the decay extends along the depressions, making a 
groove-like cavity, this should be filled by com- 
mencing the introduction of the gold at that part of 
the cavity next the gum. 

1st Mod. — Decay at or near the neck of the tooth, 
and partially or wholly overlapped by the free border 
of the gum. In this modification the gum is a great 
obstacle to the various steps in the process of filling. 
It is liable to be wounded and to bleed at every 
touch ; it exudes mucus constantly ; and it conducts 
saliva to the part with great facility. To obviate 
these difficulties, the gum must be removed some- 
what from the cavity before the filling is practicable. 
This removal of the free margin of the gum may be 
made either by cutting away, or by pressing away 
with pledgets of cotton or other appropriate substance 
placed in the cavity and projecting from it, so as to 
make pressure upon and absorption of, to a sufficient 
extent, the free margin of the gum, which will 
usually be accomplished in a day or two. The for- 



FILLING BY CLASSES AND MODIFICATIONS. 239 

mer method, however, accomplishes the object at 
once : some good hemostatic, as creasote and tannin, 
is all that is then necessary to render the filling 
immediately practicable. By means of this applica- 
tion the exndation is checked, — which, where there is 
mnch mucus eliminated, is an important item, — and 
also such a surface is given to the part that it will not 
so readily conduct the saliva. It is perhaps prefer- 
able in many cases to cut away this free margin, so 
that it shall not be in contact with the filling after 
the operation is completed. In nearly all such 
cases, by the proper application of the rubber dam 
with a perfectly-adapted clamp, the whole difficulty 
will be overcome. 

After this preparation, the cavity is formed and 
filled as usual. 

In filling cavities of the buccal portions of the 
denies sapientice, peculiar difiiculties are met with. 
The decay is frequently found two-thirds covered 
by the sum; the muscles of the cheek, thick and 
rigid, lie close against the side of the tooth ; and, in 
most cases of this kind, the view, at best, is but par- 
tial. To meet this difficulty, a clamp with a broad 
flange upon its outer blade is required for holding the 
soft parts away, and the rubber dam in its proper 
position. 

In nearlv all such cases the reflector should be 



240 CLASSIFICATION OF DECAYED CAVITIES. 

used to concentrate light upon the locality of the 
operation ; without this, the view into these cavities 
is much obscured. 

Third Class. — Anterior proximal cavities of the 
molars and bicuspids. This class of cavities in teeth 
with short, broad crowns, takes place at their necks ; 
but in those with long crowns, and with a diameter 
less at the neck than at the masticating surface, it 
begins at some distance froni the neck, toward the 
crown surface, or at the first point of contact of the 
crowns. In almost all cases of proximal fillings sepa- 
ration of the teeth is required ; the method and ex- 
tent of this will be determined by circumstances. If 
all the neighboring teeth stand in contact, it cannot 
be easily accomplished by pressure ; in this respect, 
however, there will be found a great variety ; but if 
a tooth has been extracted in the vicinity, or there 
are natural spaces between the others, it can be 
either in whole or in part. When, however, the 
teeth stand close together, they must in such case 
be separated chiefly with the chisel and file. If but 
one is decayed, the cutting should be exclusively 
from that. If two are alike affected on their proximal 
surfaces, it should be mostly from the posterior sur- 
face of the anterior tooth. In regard to the form of 
the separation effected by cutting, the general prac- 
tice formerly was to cut down the whole proximal 



FILLING BY CLASSES AND xMODIFICATIONS. 241 

side of the affected tooth, making between it and the 
adjoining one a V-shaped space, sufficient in extent 
to admit of free manipulation in all parts of the ope- 
ration of filling. By thus cutting the teeth, the form 
is marred, and often to great disadvantage in use, as 
by it the masticating surface is lessened, and food 
being crowded into such a space, produces very un- 
pleasant pressure. In order to preserve the form 
and the greatest amount of masticating surface to 
the tooth, a preferable method is to cut down from 
the masticating surface to the cavity of decay, leaving 
the lingual and buccal sides of the tooth untouched, 
except, perhaps, a little dressing that may be ren- 
dered necessary by the thinness and roughness of 
the margins. This cutting should extend about as 
far toward the centre of the tooth as the decay has 
penetrated, and be nearly as wide as the extent of 
the decay across the tooth ; it should be of dove- 
tail form, or that part of the opening next to the 
centre of the crown slightly wider than at the ante- 
rior part. This form may very readily be given by 
the properly-formed excavators, or more rapidly, and 
quite as Avell, with the fissure burs and engine. Care 
should be exercised in this particular lest the lateral 
w^alls of the cavity be weakened by this cutting ; and 
in doubtful cases, rather than incur such risk, it is 
better to avoid making the expansion altogether, and 

Q 



242 CLASSIFICATION OF DECAYED CAVITIES. 

rely upon other modes of anchorage for the filling. 
The attachment of the filling may be made by pro- 
perly-located pits and grooves. In making these, 
two points should be guarded, viz. : weakening the 
walls of the cavity, and impingement upon the pulp. 
Care, good judgment and experience are necessary to 
most fully meet these requirements. When it is 
necessary to cut from the whole proximal surface, 
there should be no shoulder or projection left at the 
neck of the tooth, but the cut surface should be plain 
from the crown to its termination at or near the 
neck. The space, of whatever form it may be, should 
be large enough to enable the operator to manipulate 
with facility, and to see as directly as possible into 
the cavity. 

Cavities of this class are various in form ; and they 
require much skill in their excavation and formation. 
Great care is to be exercised not to leave any portion 
of decay in them. By a fatal oversight, decayed 
dentine is often permitted to remain on that side 
next to the neck of the tooth ; and fillings that in 
other respects are good, are very deficient here — so 
deficient, indeed, that a sharp instrument will readily 
penetrate the softened dentine above them, or even, 
pass between the filling and the wall of the cavity. 
The removal of the decay from the cervical walls of 
all proximal cavities is an important particular, neg- 



FILLING BY CLASSES AND MODIFICATIONS. 243 

lect of which occasions thousands of failures. This 
class of cavities at this point should be most thor- 
oughly filled ; for it is a point more vulnerable than 
any other, on account of the facility with which for- 
eign substances are here lodged and retained. 

In the formation of these cavities, the cervical wall 
should be made to incline slightly outward, and the 
lateral walls, if the tooth will bear the loss, made at 
least parallel with each other ; but if that would im- 
pair its strength, grooves or pits may be made upon 
them for this purpose at proper points. When these 
cavities are large, the dentine is usually all decayed 
in that part of the cavity next to the masticating 
surface of the tooth, leaving only the enamel, which 
by the mode of separating or opening, already de- 
scribed, would be cut away. 

The rubber dam being properly adjusted, the cavity 
is ready for the filling, which is introduced, if in 
blocks, as before detailed, beginning with the cervi- 
cal wall. The caution may here again be urged, not 
to let the gold overlap the tooth, particularly at the 
cervical wall. In filling with crystal gold or cohe- 
sive foil, special retaining points will be required in 
this wall, two being generally sufl&cient, one toward 
the outer and the other toward the inner lateral wall, 
on both of which grooves may be made, if the walls 
are thick enough to admit of it. If, however, these 



244 CLASSIFICATION OF DECAYED CAVITIES. 

walls are not parallel, and will not admit of grooves, 
the crown and the cervical walls should be so shaped 
as to retain the filling. But in some cases the 
attachment of the filling is made entirely at the cer- 
vical wall ; and best by means of three pits, made 
with the square-pointed drill at different angles, 'and 
in such directions as not to interfere with the pulp. 
This kind of attachment will serve only for cohesive 
gold, which is to be very thoroughly consolidated 
into the pits, making little projections, which are so 
many anchors for fastening the filling, and built very 
firmly across from one to the other. 

^d Mod. — Decay involving a portion of the masti- 
cating surface. There are two methods of filling this 
modification. One is, to cut down the tooth or the 
projecting angles, and make a plain, oblique border 
to the cavity by the V-shaped separation already re- 
ferred to, and then fill up flush with this border. 
The filling will thus exhibit a single, uniform surface, 
at a considerable angle with the axis of the tooth. ; 
When a portion of the crown breaks down in conse- 
quence of proximal decay, it is toward the centre of 
the tooth ; usually the inner and outer corners re- 
main. If these projections are feeble and liable to 
be broken away, they should be cut down and the 
cavity filled as before described. If, however, they 
are firm, they should remain, and the cavity, pro- 



perly formed, may be filled so as to restore the 
tooth's original form, which in the molars and bicus- 
pids should be accomplished as nearly as possible, in 
order that the function of mastication should be per- 
fectly preserved. By properly-directed effort, the 
crowns of the teeth can in almost all cases, even 
where the walls are broken away, be well restored. 
Non-cohesive foil is not adaptable to this kind of 
filling, as it cannot be built in so as to withstand the 
pressure of mastication. In no case should a proxi- 
mal filling be left in contact with the adjoining tooth. 
Fourth Class. — Proximal cavities of the incisors 
and cuspidati. If the teeth are not in a crowded 
condition, and the file is not required by the extent 
of the decay, separation may be made by pressure ; 
but if the cavity is large, and the walls are thin and 
friable, cut with a thin chisel and file only till a good 
border is obtained about the cavity. Much has been 
said as to the form of these separations, some recom- 
mending that they be larger at the palatine part 
than at the labial ; others, that they be larger at the 
points than at the necks of the teeth ; some, that a 
shoulder be left at the necks ; and others, that there 
be no shoulder at all. In making these separations, 
however, the operator must be governed somewhat 
by circumstances, no general rule being applicable to 
all cases. The form of the teeth and the extent of 



246 CLASSIFICATION OF DECAYED CAVITIES. 

the decay, together with the character of the remain- 
ing enamel and dentine, will modify the form of the 
space between them. If the inner wall is thin or 
broken away, — and it is usually more friable and 
more broken than the labial wall, — it should be cut 
off more than the outer ; in which case the palatine 
aspect of the separation will be the largest- — as, in- 
deed, some prefer to make it in all cases, performing 
the remainder of the operation from the inside. 
Almost every operation upon these teeth will require 
attention and manipulation, in every step, from both 
the palatine and labial sides, in order to make secure 
every point. The precise mode of procedure must 
be determined by the case to which it is to be 
applied. The most direct approach is always to be 
employed when practicable. 

In some cases separation will be larger at the 
points of the teeth than elsewhere ; as, where there 
has been a partial fracture at the points. In cutting 
away to make the separation, no shoulder should be 
left at the neck of the tooth that, is not to be pro- 
tected by filling; any projection of that kind is 
always objectionable : foreign substances lodge upon 
and adhere to it, and, becoming vitiated, render it 
very liable to decay. The cutting* should always ex- 
tend entirely beyond the decay, but only far enough 
to make a perfectly plain border to all the cavity. 



FILLIXG BY CLASSES AND MODIFICATIONS. 247 

and should terminate without any projection It is 
highly important, in separating the anterior teeth, to 
make as little alteration as possible in their form. 
But the preservation of the tooth should not be 
jeopardized for the sake of maintaining the integrity 
of its natural form. The first consideration should 
be to obtain a space sufficient for the purposes of a 
perfect operation ; the second, to have the walls and 
border of the cavity in such a condition that an effi- 
cient filling can be made ; and the form and beauty 
of the tooth should be scrupulously preserved and 
protected, so far as the above requirements will 
permit. 

The excavation of these cavities requires very 
delicate and skillful manipulation, since they are 
very readily injured by cutting too much or at a 
wrong point. All decayed and discolored portions 
must be entirely removed, as well for the appearance 
of the tooth as for the permanency of the operation : 
after which the cavity is to be formed with great 
care. Toward the cuttino- edo"e of the tooth the den- 
tine often has all been displaced by decay, leaving 
only the two plates of enamel joined at the edge, and 
thus forming: an acute ano'le, the obliteration of which 
is always attended with risk, unless great care is 
exercised, and in many teeth it is wholly impracti- 
cable ; and still it is difficult perfectly to fill such 



248 CLASSIFICATION OF DECAYED CAVITIES. 

an acute angle. The inclination of the inner and the 
outer walls of the cavity will depend on its size ; 
when it is small or medium, they may be parallel, 
or, if necessary, slightly divergent inward ; but 
when large, it is better not to cut much of the 
healthy dentine from them, lest they be thus weak- 
ened. Small grooves, however, are admissible on 
these walls, near the bottom of the cavity, when they 
incline to the centre, and are generally, in such case, 
to be preferred to pits. In the formation of grooves 
or pits for anchorages, the dentine should never be 
cut through to the enamel ; but always dentine suffi- 
cient to protect the enamel should remain. More 
cutting is allowable on the cervical wall than else- 
where, as there is less danger here of weakening the 
tooth by excavation. In some instances the cavity, 
upon the removal of the decay, is of such extent and 
form as to admit of little or no excavation, except in 
the cervical wall ; in this, then, the chief anchorage 
is to be made, and almost the entire reliance for the 
retention of the filling must be placed upon that 
part. Such a condition renders the use of cohesive 
gold a necessity, at least if a permanent result is to 
be attained. The best method of preparing such a 
cavity is to make two or three little pits in it at 
different angles with a fine, square-pointed drill. 
Another method is, to form two pits, and make a 



FILLING BY CLASSES AND MODIFICATIONS. 249 

groove from one to the other. Some operators pre- 
pare these cavities by making pits in each of the 
walls. This, however, is unnecessary, if the cervical 
wall is properly prepared. 

In the application of the rubber dam for filling 
this class of cavities, three, four, or more teeth should 
generally be included, in order that there sliall be 
absolute security against moisture, and that the rub- 
ber shall be out of the way of the operation. The 
gold, prepared as already described, should then be 
introduced with a small plugger, serrated and some- 
what flattened about a line above the point, so as to 
be freely used when introduced into the cavity. 
The gold is taken up on the point of this plugger, and 
condensed in the pits of the cervical wall : which, 
being completely filled, and the gold extending from 
one to the other, the foundation is ready for the 
remainder of the filling. 

Great care is requisite in packing the gold into 
these cavities, perfectly to adapt and adjust it to all 
points, so as to insure its thorough contact with 
every part of the interior. If the form of the tooth 
has been measurably retained, and the border of the 
cavity is even, the surfiice of the plug should, Avhen 
finished, be slightly convex, or as nearly the original 
form of the tooth as practicable. In introducing 
the filling, reference should be had to this particular. 



250 CLASSIFICATION OF DECAYED CAVITIES. 

Two-thirds of the cavity may be filled by introducing 
the gold upon and in the direction of this cervical 
wall, and the remaining portion filled from the point 
back to the preceding filling ; or, what is probably 
better, begin at the bottom and fill to the surface, and 
then finish in the usual manner. 

For filling these cavities with non-cohesive foil, the 
special retaining points already described are not re- 
quired ; but the cervical wall of the cavity is slightly 
cut under, and the lateral walls so shaped as to 
secure the filling in place. These cavities are in 
some cases very difficult to fill with non-cohesive 
foil, whether in the form of blocks or otherwise, espe- 
cially where they are large, with the walls inclined 
to the centre, and the tooth bone friable. To force a 
wedge-shaped instrument into these fillings, for the 
purpose of condensing them, is not admissible, since 
there is thus great danger of breaking the walls of 
the cavity, and in many cases of moving the filling 
from its place. 

1st Mod. — The palatal walls broken away. Frac- 
tures of this kind assume different forms ; sometimes 
triangular, extending from the border of the cavity 
toward the centre of the tooth, and terminating in an 
acute angle ; and sometimes the border of the cavity 
is broken away irregularly, or so as to form part of a 
circle. When a triangular notch is broken out of the 



FILLING BY CLASSES AND MODIFICATIONS. 251 

wall, the operation of filling may be performed in one 
of two ways : If the portions of the wall remaining at 
each side of the fracture are thick and firm, they may 
be left, and the cavity filled, so as to restore the form 
of both the proximal and the palatal surface of the 
tooth, the latter being thus restored with gold to the 
extent of the fracture or notch. If, however, the re- 
maining portions of the wall are frail, they should be 
cut away till a border is reached sufficiently firm to 
sustain the filling. Such cutting will leave the notch 
of a circular form, and in many cases will remove 
almost the whole of the inner wall of the cavity. As 
the decay extends toward the centre of the tooth, 
owing to the concavity of its palatal surface, this wall 
becomes very thin and easily broken, this rendering 
it necessary to cut it almost all away ; but in all 
cases the excavation should be such as to leave a 
definite wall, though it be but slight, all along that 
part of the cavity. In such a case, good retaining 
points must be made in the cervical wall, since the 
permanency of the filling will depend almost entirely 
upon these. 

The surface of the filling, when finished, may be 
slightly convex from one lateral wall to the other ; 
the palatal portion of the surface, from the point of 
the tooth to its neck, will partake of the curvature of 
the border of the palatal wall ; but the anterior por- 



252 CLASSIFICATION OF DECAYED CAVITIES. 

tion will be flush with and assume the outline of the 
anterior border of the wall. Much care is requisite 
to give these filings a perfect finish, on account of the 
irregularity of surface, this in many instances being 
both convex and concave. As a material for filling 
these cavities, cohesive gold is much to be preferred. 
Indeed, in many of them it is impossible, with non- 
cohesive gold, to make a perfect filling, because they 
have no general embracing form. In such cases, the 
filling should be introduced from the palatal side of 
the tooth. 

2d Mod. — The labial wall of the cavity broken. 
The fractures of this wall are of various forms, and 
in extent corresponding with the amount of decay 
and the friability of the enamel. There is sometimes 
the triangular notch, extending far toward the middle 
of the tooth; and sometimes there are two or three 
small notches ; and still in other cases, almost the 
whole of the wall will be broken away from the point 
to the neck of the tooth. When there is simply a 
notch in the enamel, it is important for the appear- 
ance of the tooth to fill it up ; and when there is any 
prospect of success, the remaining portion of the wall 
being retained, the operation is to be performed as 
already described for the palatal wall. It will, how- 
ever, in many cases, be necessary to cut away part 
of the remaining portions of the wall, leaving the 



FILLING BY CLASSES AND MODIFICATIONS. 253 

general form of the border somewhat circular, though 
the notch form, in some instances, is not wholly 
obliterated. 

In filling this kind of cavity, it is desirable to re- 
store as much as possible the form of the tooth. The 
filling should be built out from the border of the wall 
almost to a line with thQ tooth's original proportions, 
so that the whole surface of the filling will be con- 
vex ; and it should be finished with great care, the 
Scotch stone, buff, or stipple finish being preferable 
for that part exposed to view. 

od 3Iod. — The cavity extending almost to the point 
of the tooth, and terminating or running out at the 
surface. In the preparation of this cavity, that part 
next the point of the tooth should be cut in enough 
to form a definite wall there, and to give room for 
sufficient thickness and strength in that portion of 
the plug. Many operators attempt to fill this kind 
of cavity without such precaution, terminating that 
part of the plug in a thin edge. This method is very 
objectionable, for the thin edge will become more or 
less separated from the tooth, and foreign substances 
will be forced under it, and, becoming vitiated, induce 
decay. Indeed, a defect of this kind is a sure pre- 
cursor of the destruction of the filling. The intro- 
duction and finish of the filling in this kind of cavity 
are the same as first described for this class ; and the 



254 CLASSIFICATION OF DECAYED CAVITIES. 

admonition may be repeated that there be left no 
thin overlappings of the filling that may become 
changed in position. 

Aith Mod. — The cavity large, and the lateral walls 
thin and friable. In this kind of cavity the dentine 
is almost entirely removed from the lateral walls, 
leaving little else than the enamel after the excava- 
tion of the decay. These walls will of course admit 
of no cutting for the purpose of giving them a more 
desirable form. The cervical wall must be shaped 
with special reference to a retention of the filling, to 
consolidate which the requisite pressure must be ap- 
plied almost exclusively toward this wall. It requires 
extreme care to condense the gold in cavities of this 
kind, and adapt it to the lateral walls without frac- 
turing them ; various methods have been suggested 
to prevent such an accident. Pluggers with very fine 
points are recommended, as consolidating the gold 
with much less pressure than would be necessary 
with large-pointed instruments. But it has been 
maintained that a perfect adaptation of the gold to 
the inner parts of these walls is not important, pro- 
vided the adaptation at the border is perfect. It is 
certain, however, that a filling thus imperfectly 
adapted is not so good as though the gold were in 
contact with all points of the cavity; and besides, 
the liability of fracturing the wall is just as great in 



FILLING BY CLASSES AND MODIFICATIONS. 255 

consolidating at the border as ^vithin. The walls may 
be sustained by enveloping the tooth to the borders 
of the cavity with some material perfectly adaptable 
to it, and capable of resisting the force applied in the 
process of consolidation, as gutta-percha or plaster of 
Paris. If the former is employed, it should be soft- 
ened by warming, moulded upon the tooth, and then 
permitted to harden. The hardening may be facili- 
tated by throwing cold water on it from a syringe. 
It is then to be trimmed even with the border of the 
cavity, so as to admit the filling. If plaster of Paris 
is to be used, it should be of the best quality. Yet 
gutta-percha is to be preferred. But a better protec- 
tion than either may be made of fusible metal, taking 
an impression of the tooth, and from that moulding 
the shield. In these fillings, when the enamel is 
clear and translucent, the gold will be visible through 
it. To obviate this difficulty, and give strength to 
the frail walls after the cavity is formed and thor- 
oughly cleansed, it should be filled with oxy-chloride 
of zinc. Great care must be exercised in introducing 
this, to secure its perfect adaptation to every part of 
the cavity ; and after hardening has taken place, 
excavate as may be requisite, leaving enough to con- 
stitute a good lining and support to the thin walls, 
and obscure the view of the gold. 

The natural color of the tooth may be in this way 



256 CLASSIFICATION OF DECAYED CAVITIES. 

SO well restored and maintained as to elude detec- 
tion; at the border of the orifice the gold should 
come in contact with the dentine or enamel. In 
almost all cases of thin weak borders, the gold should 
be built on and over them, so as to form a shield or 
protection against fracture or undue- wear. All such 
overlapping portions should be made so thick and 
firm as not to be displaced or moved. 

The loss of a portion of the cutting edge of the in- 
cisors by extensive decay is often met with. In all 
such cases, when the dentine is of good structure, it 
is practicable to restore the lost part to a greater or 
less extent by building up with gold. In order to 
make successful operations in such cases, several 
points must be regarded. The dentine and enamel 
should be of good structure ; the cavity toward the 
neck of the tooth of such a form as to afford the best 
anchorage ; this may consist of pits with grooves 
running out from them. Teeth with thick short 
crowns present the best opportunity for such an ope- 
ration ; indeed, upon that class of incisors with long 
thin crowns, such an operation is not usually practic- 
able, and generally these teeth present such a con- 
trast in color with the gold as to be quite objection- 
able. In the operation the manipulation must be 
such as to secure the most thorough welding of the 
portions of gold of which the filling is composed. 



FILLING BY CLASSES AND MODIFICATIONS. 257 

With good attachments, gold well prepared and in 
good condition, and properly manipulated, the filling 
may be built up to any desired extent without 
danger of being either drawn out or broken down. 
The finish should be such as has already been 
described for fillings exposed to view. 

Fifth Class. — Posterior proximal cavities of the 
molars and bicuspids. These are separated like ante- 
rior proximal cavities, except that, ordinarily, to open 
them up, more is to be cut from the tooth, on account 
of the greater difficulty of approaching, inspecting 
and operating in the cavity. The same general prin- 
ciples are applicable to the opening of this class of 
cavities as to that of the third class, except that 
pressure for separating cannot be as frequently em- 
ployed, since the cavity will not be as well exposed 
by this as by cutting, nor rendered so easy of ap- 
proach. Indeed, in operating on these cavities, the 
use of the mirror is often necessary, it being im- 
possible to obtain a direct view into them after 
having cut away all that it is admissible to re- 
move. This difficulty is almost wholly obviated 
by the method of working through the masticating 
surface of the tooth into the cavity of decay, as 
already described. The accessibility of these cavi- 
ties will depend on circumstances, such as the loca- 
tion of the tooth, its inclination, the size of the 



258 CLASSIFICATION OF DECAYED CAVITIES. 

mouth, the flexibility of the muscles, and the ability 
of the patient to open the mouth, and keep it open. 
Generally, in operating on these cavities for the re- 
moval of decay, for the formation and the filling, 
curved instruments will be required, but their curva- 
ture should not be greater than the necessity of the 
case demands. 

The cavity, during its preparation, must be fre- 
quently examined. Its general form, and the size, 
kind, and location of the retaining-points, will be the 
same as in class third. The lateral walls, if the cavity 
is not too large, should be made parallel with each 
other; the undercutting at the crown wall will be less 
than in anterior proximal cavities ; and the cervical 
wall should have a slightly inward inclination — the 
reverse of the same wall in anterior proximal cavities. 
In this latter there should be made, at different 
angles, pits for retaining-points — three if the tooth 
is a molar, and two if a bicuspid. For making these 
pits, the engine right-angle hand-piece will be found 
applicable and convenient. 

Preparatory to introducing the filling, the same 
appliances should be used to protect the cavity from 
moisture that have been described elsewhere. Great 
care should be exercised in introducing and securing 
the first portions of gold. The size, form and loca- 
tion of the anchorage points should be carefully 



FILLING BY CLASSES AND MODIFICATIONS. 259 

notedj and into these the filling should he very per- 
fectly introduced ; here the most thorough welding 
of the gold should he made, so that each piece when 
adjusted will he immovahly fixed. The gold extend- 
ing from one anchorage to another constitutes the 
foundation upon which the subsequent part of the 
filling is to he huilt. This may proceed uniformly 
from the cervical part of the cavity to the masticat- 
ing surface of the crown, if, as is usual, the prepared 
cavity involves this surface. 

When the separation made between the teeth con- 
stitutes a V-shaped space, the filling should have a 
single plain or slightly convex surface, which will be 
at a greater or less angle with the axis of the tooth 
according to the greater or less amount cut away in 
the separation. Much care is requisite in order to 
make perfect work along the borders of the lateral 
walls of the cavity ; these should be secured as the 
work progresses, and should in no case be left to 
receive attention after the body of the filling is intro- 
duced. 

When the lateral walls have been cut away, as was 
formerly the practice, it is much more difficult to re- 
store the crown to its original form and size than by 
the method now pursued — retaining the lateral walls 
and filling flush Avith them, and also protecting the 
edges by the filling. 



260 CLASSIFICATION OF DECAYED CAVITIES. 

It is claimed that the difficulty of filling this class 
of cavities is much diminished by the use of the 
matrix. This appliance, in its present form, is the 
device of Dr. Lewis Jack. He gives the following 
description of it and its use : — " These little affairs 
are made of a variety of shapes, sizes, and thick- 
nesses. They are formed of slightly wedge-shaped 
pieces of steel, and are, as the cut designates, hol- 
lowed out at their thicker edge, which depression 
terminates at the thinner edge. At the part of the 
depression designed to give shape to the buccal edge 
of the filling, the cut is generally abrupt and deep ; 
at the inner portion it is more shallow and more in- 
clined. It will be observed that the depression 
widens as it passes toward the thinner edge, to follow 
the usual form of proximal cavities. The lower and 
thin edge is rounded, to outline the curved margin of 
the cervical walls, and to effect pressure upon either 
the gum or the appliances used to stop the escape of 
mucus and blood from this tissue. 

" The plain parts of the face are file-cut, or coarsely 
draw-filed. The reverse side is in most cases plain 
and smooth, excepting a small portion at the thin 
edge, which is file-cut. ... At each end a square 
cut is made, that the ends of the plier for adjusting 
them will fit into. . . . Quite a number of pairs 
are necessary to meet the requirements of the differ- 



FILLING BY CLASSES AND MODIFICATIONS, 



261 



ing cases ; but for the ordinary-sized simple proximal 
cavities, a dozen pairs, varying in width, in thickness 
and in size of depression, are all that I have found 
necessary. . . . The ^ ^ig- ^^• 

character of the modifi- 
cations that should be 
made in these will de- 
pend somewhat upon 
the desired end, since 
either a flat, contour, or 
excessively convex sur- 
face may be produced 
at the pleasure of the 
operator, or to suit the 
needs of the individual 
operation, by varying 
the form and depth of 
the depression." 

The ordinary forms 
of these appliances are 
represented by Figure 
88. 

Some additional de- 
scription of the matrices, 
and the method of using them, Avill be given in the 
Appendix, Sec. D. 

A piece of polished metal, of the proper thickness. 




262 CLASSIFICATION OF DECAYED CAVITIES. 

may be placed back of the cavity against the adjoining 
tooth, introducing the filling, and consolidating it 
firmly up to this piece of metal. The lost portion 
of the crown being thus restored, the metal is then 
removed, and the filling dressed off and finished in 
the manner described heretofore. 

But when the opening is made by cutting in from, 
the masticating surface, the entire opening made in 
the tooth, both by the decay and the operation, will 
be completely filled, and the form of the tooth en- 
tirely restored ; the filling will then present a proxi- 
mal and crown surface. When the teeth, molars and 
bicuspids, are decayed upon their contiguous sides, 
the cavities in both may be prepared as already de- 
scribed ; the proper separation and excavation having 
been made, both may be filled together, the gold ex- 
tending across the space, and after being filled up 
flush with the masticating surfaces, the separation is 
effected by dividing the gold with a separating file. 
Thus, each cavity is completely filled, and there is 
always gold enough upon the proximal parts to 
secure a complete finish. This method is not always 
practicable, as, for instance, when there is a large 
space, or when it is not desirable to fully restore the 
form of each tooth ; but occasionally it may be used 
with advantage. The labor, tedium, and difficulty of 
manipulation are increased the farther back in the 



FILLING BY CLASSES AND MODIFICATIONS. 263 

mouth the decay is situated. The modifications of 
this class are the same as those of the third class of 
cavities, and, except the second modification, are sus- 
ceptible of the same methods of filling. 

Special Cases. — The first case that we shall con- 
sider here, consists in a complication of proximal 
decay with decay on the buccal or palatal portion of 
the tooth, thus undercutting one of the crown angles. 
Sometimes these decays are on both sides, in the 
form of transverse grooves, meeting at the corner of 
the tooth. In such cases, if the pendent crown 
angle of the tooth is firm and strong, the cavities 
may be formed in the proper manner, and filled with- 
out interfering with the masticating portion of the 
tooth at all ; but if the pendent portion is friable, it 
should be cut away, and the corner built up with 
gold. The method of forming the part to be filled 
will depend on the extent of the decay. When this 
is large, a greater number of retaining-points will be 
required than when it is small ; and these should be 
located at such parts as will make them most tena- 
cious of the gold, and best conserve the strength of 
the tooth. The filling may be built up so as to 
restore the original form of the tooth, thus presenting 
three surfaces, the proximal, the buccal or palatal, 
and the masticatory ; or, it may be made with a 
single slightly convex surface, adapted and finished 



264 CLASSIFICATION OP DECAYED CAVITIES. 

most completely at all its borders. This kind of 
filling can be made only with cohesive gold. 

The palatal portion of the crown broken away^ leav- 
ing the outer portion standing — -]^ulp not exposed,- — The 
tooth in such case is decayed away, so that the floor 
of solid dentine is near the margin of the gum, the 
labial third of the crown still standing. The decay 
having been all removed, four or five little pits 
should be made on this floor, as near its circumfer- 
ence as practicable ; and a small groove may be cut 
from one of these pits to another all round near the 
edge of the floor. Then two little pits should be 
made at the base of the standing portion of the 
crown, if practicable, without interfering with the 
pulp, provided it is still living. The tooth thus pre- 
pared and properly protected by the use of the rub- 
ber dam, the filling may proceed. 

For building up a crown of this kind, only cohesive 
gold can be used ; and this should be of the best pre- 
paration, and in the most perfect condition, since it 
is important that the different portions of the filling 
be most thoroughly united. The instruments em- 
ployed in the operation should be of the best kind 
and in the best condition, the serrate points being 
definite and sharp, though not too long ; those with 
four, six, or eight points may be advantageously used 
for packing the gold. But care must be exercised 



FILLING BY CLASSES AND MODIFICATIONS. 265 

lest these fine points be turned ; for when that is the 
case, the instrument is liable to displace the portion 
of gold, and thus break up its first attachment during 
the process of consolidation ; and when this is broken, 
the piece of gold cannot again be made to adhere as 
perfectly as before. 

With everything thus in readiness, the retaining- 
points are to be all filled, the gold extending from 
one to the other ; this is then to be built all over 
the bottom of the part to be restored, projecting a 
little beyond the periphery, and being perfectly con- 
solidated there, and kept somewhat higher round the 
border than in the centre. The gold should be built 
up in this manner till the crown is large enough, 
after dressing, to give the desired size and form. In 
finishing up, the aim should be to restore as perfectly 
as possible the lost form of the tooth. The adapta- 
tion of the gold, too, to the standing portion of the 
crown should be most complete ; imperfection in this 
respect impairs the appearance of the work, and 
jeopardizes the security of the operation. 

Occasionally the crown of a molar tooth is found 
decayed off all round, almost to the margin of the 
gum, the pulp having previously receded so as not 
to be exposed. It is in such case desirable to re- 
store the lost portion of the crown, and make a mas- 
ticating surface such as shaU antagonize properly 



266 CLASSIFICATION OF DECAYED CAVITIES. 

with the teeth of the opposite jaw. As yet, there is 
no other method of accomplishing this than by build- 
ing it up with gold — cohesive gold foil, or crystal 
gold. In the preparation for this crown of gold, the 
edge should be dressed smooth and even all round 
the tooth; then six or eight deep pits should be 
made at different angles on the base thus pre- 
pared ; and they should be bored with a drill larger 
than is commonly used for retaining-points. These 
pits may be slightly enlarged within. The method 
of building up the crown is just the same as that de- 
scribed for building up part of a crown, the pits being 
first filled, then joined together, and the gold ex- 
tended all over the part to be covered by the filling. 
In extending the gold from a retaining-point or 
points, it is necessary to build up to a considerable 
thickness above the orifice of the pit. The portion 
of gold extending along on the tooth from the pit 
should be quite thick and firm, so as not to curl up 
from its position, on the addition of subsequent por- 
tions. Every particle of gold, indeed, should be so 
manipulated, that it will securely maintain its first 
position. The permanency of the operation will depend 
very much upon this precaution. The gold should ex- 
tend somewhat beyond the circumference of the tooth 
all around, in order to a thorough adaptation and finish. 
The foundation thus prepared, and kept free from 



FILLING BY CLASSES AND MODIFICATIONS. 267 

moisture, the crown is easily built up by the ordinary 
method of packing the gold. Any desired shape can 
be given to this artificial crown ; but, of course, that 
which most nearly resembles the form of the natural 
crown is in all cases to be desired. The masticating 
surface of this gold crown is to be formed from the 
indications given by the antagonizing teeth. Such 
crowns will wear for years, and perform all the func- 
tions of the natural organs. Artificial crowns of this 
kind have been attached to the tooth, by screwing 
into the pits small pieces of gold wire at different" 
angles, and then building up round and between 
them with the gold foil, on the principle already de- 
scribed, thus making these wires serve as so many 
anchors for fastening the work. The use of screws 
for securing fillings in these extreme cases was sug- 
gested, and perhaps occasionally used, more than 
twenty years ago, by Dr. W. H. Dwinelle. But 
during the last four years their practicability has been 
more fully demonstrated by Dr. Mack^ who devised 
a set of instruments by which small gold screws can 
be very readily introduced wherever they are re- 
quired. These screws, as made by Dr. Mack, are 
screw-cut the entire length, except a small portion 
of the outer end, which is made flat and wedge- 
shaped; upon this flattened part the screwdriver 
acts when the screw is introduced. 



268 



CLASSIFICATION OF DECAYED CAVITIES. 



Something additional in this direction seemed desi- 
rable, and to meet this want, Dr. E. Osmond, about 
four years ago, made an improved screw, and con- 
structed a set of instruments for introducing it. 
These are represented in the following cut. 

Fig. 89. 




These screws are made of twenty-carat gold, an- 
nealed and split about half-way, once or twice, so as 
to form two or four arms. These are opened and 
turned down, as may be necessary after being in- 
serted. 

They are made of different sizes, to meet the re- 
quirements of different cases, and the instruments are 
adapted to the different screws. The teeth repre- 
sented in this cut show large converging cavities, in 
which the screws are fixed, ready for the attachment 
of the filling. 

It has been suggested that making barbes on the 



FILLING BY CLASSES AND MODIFICATIONS. 269 

screws would give greater security to the filling than 
the plain screw, yet with Dr. Osmond's screws the 
utmost security is attained. Of course cohesive gold 
is always to be used with this kind of anchorage. 

Security of attachment of these large fillings may 
in many cases be quite as well attained with the 
foil alone. But good tooth-structure and properly- 
located and well-formed anchorages are very im- 
portant. 

Filling large cavities on the labial surfaces of the 
superior incisors. — These cavities are usually super- 
ficial, and frequently co-extensive with a considerable 
part of the surface of the tooth. A method of filling 
them, somewhat novel, though not without merit, has 
been introduced to the notice of the profession by 
Dr. Volck, it having been first suggested to him, how- 
ever, by Dr. Maynard. It consists in filling up the 
cavity principally with a piece of enamel, as near the 
color of the tooth as possible. The cavity, when 
nearly round, should be formed with a wheel bur of 
the proper size ; and after having been thus reamed 
out, a slight undercutting should be made all round 
with an excavator. Then a piece of enamel being 
selected, it is dressed to a proper thickness, which 
should be slightly greater than the cavity's depth, 
and to a perfectly circular form, its size being such 
as to let it drop, with a little play, into the cavity, 



270 CLASSIFICATION OF DECAYED CAVITIES. 

and the edge of it beveled from without. For fasten- 
ing this in the cavity, roll a strip of several thick- 
nesses of gold foil round its edge, and add as much as 
can be forced in with it. Thus prepared, set it in 
place in the cavity, and then condense the gold down 
into the groove all round with a thin-pointed plugger, 
more gold being added, if necessary, to fill the groove 
completely full. Afterwards, with the file, stone, 
and burnisher, dress off the whole to a proper level 
with the surrounding tooth, finishing very carefully 
with the burnisher. The unsightliness of a large 
gold filling on a front tooth is thus obviated, no 
metal except that composing the ring of attachment 
in the groove being exposed to view. It is a beauti- 
ful operation, and one whose successful accomplish- 
ment will require considerable constructive talent 
and skill. 

A better method of performing this operation, for 
many cases, at least, is by setting a porcelain filling 
or block in oxy-chloride of zinc. The cavity should 
be prepared as usual, the borders neatly trimmed, 
and made as free as possible from irregularities. 
Select a section of a porcelain tooth, as near the 
color and surface conformation of the tooth to be 
filled as possible ; then fit the piece to be supplied 
carefully, making it to conform to the cavity as accu- 
rately as possible ; it should be a little thinner than 



FILLING BY CLASSES AND MODIFICATIONS. 271 

the depth of the cavity. The cavity now being 
secured against moisture, and made perfectly dry, 
"oxy-chloride of zinc, or better, perhaps, Guilloi's 
cement, because it hardens less rapidly, should be 
prepared of such a consistence as to permit the accu- 
rate adjustment of the porcelain filling. This, after 
being put in place, should not be disturbed nor moist- 
ened till the cement is well set. It is better to cover 
the joint with wax or varnish, and let it remain a 
day or two before attempting to dress or polish the 
porcelain ; if, however, the work has been perfectly 
done, nothing else will be required. 

An operation performed in this manner is prefer- 
able to a filling of gold for this class of cavities ; it is 
less apparent to the view; indeed, when a proper 
selection has been made, and the adaptation is good, 
it will not be visible at all except under the closest 
observation ; and usually the tooth will be as well 
protected, and in many instances better, than by the 
common method of filling. 

The use of platinum and gold foil together, as 
suggested by Dr. Black, for filling these cavities, is 
better than gold, so far as appearance is concerned ; 
the striking contrast between the color of the gold 
alone and that of the tooth is materially relieved. 



CHAPTER VIII, 

PATHOLOGICAL CONDITIONS. • 

Hitherto, in the consideration of the treatment of 
caries, the subject of the vitality and pathological 
conditions of the teeth has been intentionally omitted. 
It now remains to describe the diseased conditions to 
which the teeth are subject, and the treatment which 
those respective conditions indicate. This is an im- 
portant department of the practice, since upon skill 
in this, as well as upon the manner of performing the 
work, the success of the operation depends. 

Premising that our remarks on this branch of the 
subject are predicated on the fact admitted, that the 
teeth possess vitality, we proceed to consider the 
pathological conditions to which, in common with, all 
vital tissues, they are liable. There is but one diseased 
condition of living dentine, anterior to decay, that 
presents any considerable difficulty in the ordinary 
operation of filling teeth, and that is, inflammation, 
or exalted sensibility. This condition was referred 
to in the remarks on the treatment of caries, as being 
one that most generally accompanies decay of the 



SENSITIVE DENTINE. 273 

teeth. Whether or not this afTection is real inflam- 
matioiij is a point that has been considerably contro- 
verted ; and the assertion has been made that it is of 
no consequence whether it is or not, provided we 
understand the true method of treating it. This, 
however, is not to be so readily conceded; for the 
confession that we do not know what to call a thing, 
generally implies an ignorance of its character and 
phenomena. While the term inflammation conveys a 
more definite notion, the phrase exalted senBilility is 
very vague in meaning. That it is true inflammation, 
is the opinion of our best dental writers. 

The dentine is endowed with the functions of ab- 
sorption, nutrition, and secretion, modified somewhat 
by the peculiarity of the structure — characteristics 
that ahvays imply a susceptibility of inflammation. 
In inflammation of the soft parts there are present 
various indications, — as, pain, redness, swelling, and 
increased heat. But in dentine, on account of its 
peculiar structure, all these indications cannot be 
manifested : for instance, redness, since the red glob- 
ules do not circulate through it ; nor swelling, since 
the structure is dense — devoid of mobility ; nor per- 
ceptibly increased heat, since the circulation is of too 
low a grade. But one of the most definite indications 
of inflammation, namely, exalted sensibility, is pre- 
sent here in a very marked degree; and there are 



274 PATHOLOGICAL CONDITIONS. 

various other circumstances that indicate this condi- 
tion to be real inflammation : the same irritating 
causes that induce inflammation in the more highly 
organized parts, occasion it in the living dentine. 
This condition of the teeth is always affected by a 
general inflammatory diathesis, and their sensitive- 
ness, when there is this general tendency to inflam- 
mation, is always increased, and local treatment in 
such case will commonly be inefficient ; a modifica- 
tion of such a condition of the system produces a 
corresponding change in the affected teeth ; and those 
remedial agents which are employed in the topical 
treatment of inflammation elsewhere are successfully 
used in the treatment of inflamed dentine. From all 
these circumstances we infer that this affection of the 
teeth is a real inflammation. 

As has been already remarked, the only definite 
and direct indication of inflammation of the dentine 
is exalted sensibility, though this is not an immediate 
consequence of that condition, independent of exter- 
nal circumstances ; for the pain resulting directly 
from inflammation in the soft parts is not experienced 
here, by reason of the low grade of vitality and the 
feeble circulation. But the teeth in a state of inflam- 
mation will suffer pain when subjected to sudden 
variations of temperature, whether induced by the 
air, by fluids, or by contact with any hard substance ; 



SENSITIVE DENTINE. 275 

and when subjected to the influence of agents that 
irritate the nerve-tissue anywhere, such as acids, 
some alkalies, salts, &c. In regard to degree, extent, 
and location, this affection exhibits a variety of mani- 
festations ; in degree, from the most mild to the most 
intense — sometimes fixed at a uniform pitch of pain, 
and sometimes passing through the gamut of torture 
up to the most acute anguish. The character of the 
affection is modified by differences in the organic 
structure of the teeth, those most vascular and most 
highly organized being most readily and most exten- 
sively involved ; and therefore the teeth of the young 
are generally more liable to it than those of the old. 
So, too, persons of a plethoric or a strumous habit, as 
well as those in a febrile condition, are peculiarly 
predisposed to this affection. Sometimes irritation 
or disturbance of other organs of the system sympa- 
thetically or secondarily induce inflammation of the 
dentine. Uterine irritation frequently does so, and 
hence, during pregnancy, or a protracted suppression 
of the catamenia, the teeth are very liable to be 
thus affected, and, if decayed, to become very sensi- 
tive. 

Inflammation of the dentine will sometimes be 
exhibited in various degrees in different teeth in the 
same mouth at one time. This is owing to differ- 
ences in the organic structure of teeth developed at 



276 PATHOLOGICAL CONDITIONS. 

different periods of life, to differences of their loca- 
tion in the mouth, and to differences of exposure to 
those agencies which are apt to induce the condition. 
As to the extent of this inflammation, it may be con- 
fined to a thin lamina of bone immediately beneath 
the decomposed portion, or may extend deep into the 
body of the tooth, and, indeed, in some cases, pervade 
the dentine of the entire crown. This latter extent, 
however, is not likely to occur, unless there is a gen- 
eral predisposition : if it is produced by local causes, 
it will not, in general, penetrate very deeply into the 
dentine. Most commonly, the greatest sensitiveness 
is at the union of the dentine with the enamel ; but 
sometimes it is confined to a small point within the 
cavity, either because there is a concentration of 
nerve-fibrils there, or because there has been a 
determination of the irritating influences to that 
points— the former being probably the more frequent. 
The greatest sensitiveness, as already remarked, is 
generally at the surface of the dentine, because that 
is the termination of the nerve-fibrils which ramify 
the dentine, and wherever nerve-fibre terminates, 
there always we may look for exalted sensibility. 
Hence it is that decay of the teeth is often found to 
be more sensitive in its incipient stages than when 
it has become more advanced. 

Treatment of Inflamed Dentine, — There are several 



TREATMENT OF SENSITIVE DENTINE. 277 

methods of treatment that may be employed to 
remedy this condition. In many cases, where time 
and circumstances will permit, a removal of all irri- 
tating agents from the affected parts will enable 
nature to effect a restoration to health. All decom- 
posed dentine is to be removed from the cavity, 
every exciting influence in it withdrawn or neutral- 
ized, and the cavity itself perfectly filled with some 
non-conducting material, so as entirely to exclude all 
foreign substances. So far as non-conduction of heat 
is concerned, there is perhaps nothing- better than 
" Hill's stopping ;" or in some cases tin or gold may 
be used ; but when either of these is employed for 
this treatment, some non-conducting substance §hould 
be placed between the filling and the sensitive den- 
tine. The length of time necessary for the restora- 
tion of the affected part, under this treatment, will 
be much varied by circumstances. The cases sus- 
ceptible of this kind of treatment are those in which 
there is no constitutional predisposition, in which the 
vitality is strong, and the recuperative power vigor- 
ous. When the temporary fillings are made of 
metals, the patient should be careful to protect them 
from sudden changes of temperature. For such 
fillings, in case they are required but for a short 
time, a lock of cotton saturated with a solution of 
gutta-percha and chloroform may be used. 



278 PATHOLOGICAL CONDITIONS. 

But in cases in which the vitality is low, the 
afFection chronic, the exciting cause highly irritating, 
and the general diathesis inflammatory, nature, un- 
aided, will not affect a cure. In such circumstances, 
therapeutic treatment is indicated. The agents em- 
ployed in topical treatment may be divided into two 
classes : first, resolvents, or those which have for 
their object an entire restoration to health of the part 
affected; and second, escharotics, or those which 
have for their object the death of a portion or all of 
the diseased part. The former class of agents is of 
course preferable, when the object can be promptly 
accomplished by their use, and especially preferable 
to those agents which endanger the vitality of the 
whole tooth. In very many cases in which topical 
applications are indicated, constitutional treatment is 
also required ; and this should be of an antiphlogistic 
character. The immediately adjacent parts, too, as 
the gums, the mucous membrane, etc., should be 
carefully regarded. Indeed, treatment of the gums 
by counter-irritation, depletion, and various prepara- 
tions, such as the conditions may indicate, will often 
be found pre-requisite to a successful treatment of 
sensitive dentine by topical applications. 

There are very few agents used simply as resolv- 
ents. The properties characteristic of this class of 
agents are tonic, stimulant, sedative, and astringent. 



TREATMENT OF SENSITIVE DENTINE. 279 

Capsicum may fitly represent the stimulant; Peru- 
vian bark, and gum myrrh, the tonic ; tannin the 
astringent; and opiates the sedative principle. As- 
tringents, stimulants, and sedatives all tend to coun- 
teract inflammation. The agents of this class are 
not very extensively used in the treatment of den- 
tine, not because they are not ultimately efficient, 
but because their action is less vigorous than that of 
some other agents. When, however, time and cir- 
cumstances will permit, mild treatment, if efficient, is 
to be preferred. 

But there are many cases in which, for want of 
time, something more rapid in its action is required. 
Of this character is the second class of therapeutic 
agents, namely, escharotics, or those which by their 
action destroy a portion of the tissue with which 
they come in contact. It may be well to notice, 
separately, the preparations commonly used for this 
purpose. 

Tannin, or Tannic Acid. — This is the active prin- 
ciple of vegetable astringents, and is found most 
abundant in nutgalls. It unites with albumen, fibrin, 
and gelatin, forming with them insoluble tannates. 
Its medicinal influence is almost necessarily topical, 
since the promptness of its action on albuminous sub- 
stances, and the insolubility of its compounds with 
them, prevent its admission into the general circula- 



280 PATHOLOaiCAL CONDITIONS. 

tion. The action of tannin on dentine has been 
already explained. Either its aqueous or its alcholic 
solution may be employed, the latter being the better 
and more convenient preparation. It is however re- 
cently used by solution in creosote and glycerin, 
which constitute a very valuable preparation. Where 
tannin is applied to dentine, there is formed a tannate 
of albumen, which, being insoluble, protects from irri- 
tation, and probably incites to healthy condition the 
living parts beneath it. 

Creosote, or Carbolic Acid. — Formerly, creosote was 
obtained by distillation of wood, and differed some- 
what from that in present use, which is prepared by 
distillation of coal tar. It dissolves freely in alcohol 
or ether, and sparingly in water ; its action may, 
therefore, be modified by dilution. Creosote produces 
its caustic effects by its affinity for albumen and 
gelatin, with which it forms insoluble compounds ; 
and from its modus operandi, it is evident that the 
popular opinion that it promotes decay of the teeth 
is an error. 

Nitrate of Silver. — This salt is a powerful caustic, 
whether applied to soft parts or to bony tissue. Its 
action is somewhat complex. Nitric acid is liberated 
by the decomposition of the salt when in contact 
with organic matter. Nitrate of silver has a strong 
affinity for albumen, uniting with it without difficulty; 



TREATMENT OF SENSITIVE DENTINE. 281 ' 

and the compound thus formed is soluble in nitric 
acid. When the nitrate is applied to the skin, the 
immediate result is a whitish mark caused by a union 
of the salt with the albumen of the cuticle ; but this 
soon turns black, by the reduction of the salt and the 
liberation of the oxide of silver, when for each atom 
of this set free there is liberated an equivalent of 
nitric acid. There is here, then, an agent that acts 
promptly on the gelatinous portion of the tooth, de- 
stroying its vitality to the extent of the combination 
which takes place, and that, by the decomposition of 
part of the salt, and the consequent liberation of part 
of the acid, also acts with energy on the calcareous 
portion. The compound formed by the nitrate with 
the organic constituents of the tooth, is insoluble ex- 
cept with a few substances, and therefore protects 
the subjacent parts ; and the precipitation of the 
reduced oxide on the surface, it is claimed, affords 
some additional protection. The insolubility of the 
compound above mentioned prevents an absorption 
of the nitrate by the dentine, and renders its action 
necessarily superficial. When the nitrate is neutral- 
ized by a union with it of an equivalent of the con- 
stituents of the dentine, no further chemical action is 
possible. The compound formed by this union is 
soluble in a dilution of the nitrate ; and if this be 
applied in too great a quantity, there may be a larger 



282 PATHOLOGICAL CONDITIONS. 

loss of substance than is desirable or at all necessary ; 
for as long as free nitrate remains in solution in the 
cavity, the insoluble compound is not precipitated, 
and the surface is therefore exposed to the continued 
action. It is preferable to employ the nitrate in the 
solid state, or, when this is not practicable, in a con- 
centrated solution, and small quantity, rather than in 
a copious dilution and repeated application. 

From the observations already made, it is quite 
evident that no harm can result to the tooth from a 
proper application of this agent, beyond the portion 
of it immediately acted upon. The nitrate cannot be 
absorbed by dentine, but it stimulates the subjacent 
dentine to more healthy action ; though some main- 
tain that it is not as efficient in this respect as some 
proper chloride. It acts to a greater depth than 
tannin or creosote, but not so deep as chloride of zinc, 
nor with so much pain. Great care should be exer- 
cised that its contact be permitted no further than 
its action is desired. 

Chloride of Zinc. — This agent has been extensively, 
though much less now than formerly, used in the 
treatment of sensitive dentine. It exerts an anti- 
septic and disinfectant, as well as an escharotic, influ- 
ence. In its operation it decomposes ; the chlorine 
obtaining hydrogen by decomposition of water, 
hydrochloric acid is formed; this unites with the 



TREATMENT OF SENSITIVE DENTINE. 283 

calcareous elements, and breaks down the animal 
constituent as well. It is milder in solution than in 
solid, and less efficient and less painful. It is soluble 
in water, alcohol, ether, or chloroform. The etherial 
and the chloroformal solutions are, in their action, 
least painful of all the forms in which this chloride is 
applied. The union of this agent with the gelatinous 
constituent of the tooth is also more prompt in solu- 
tion than in solid. The ether and the chloroform may 
lessen the pain by their ansesthetic influence. In the 
use of the chloride, or any other active caustic, it is 
important to bear in mind the exalted vitality which 
follows its application ; and the operation should be 
immediately performed. In the teeth of young per- 
sons, or those in which the animal constituent greatly 
predominates, the vitality will be more promptly 
aroused than in those of an opposite texture, and the 
change, too, will be greater. If the inflammation is 
confined to a thin lamina, it will be almost instantly 
allayed by the application of the chloride, and the 
cavity may be excavated as though there had never 
been exalted sensibility in it ; but if the operation be 
delayed any considerable time, the tooth will often 
be found in a worse condition for excavating than 
before the application. The remarks on absorption 
under the head of nitrate of silver apply with equal 
force here : there is not the least danorer from this 



284 PATHOLOGICAL CONDITIONS. 

source ; indeed, there can be none, even when the 
chloride is applied to the soft parts. 

Ter chloride of Gold. — Of this preparation the ethe- 
rial solution only has been employed. This acts 
with great promptness on the dentine, forming an 
insoluble compound with the gelatinous elements, 
and the chlorine performing its role upon the calca- 
reous portion. On account of the promptness with 
which this agent operates, neither the pain nor the 
disturbance of the subjacent parts caused by it is 
great. This substance is very liable to decomposi- 
tion. By exposure to air or light, the gold is pre- 
cipitated in the metallic form. But protected from 
these, it may be preserved for a long time. This 
agent will not be absorbed by the dentine. 

Arsenious Acid. — The modus operandi of this agent 
is involved in obscurity. In regard to its topical 
action. Professor Bache says : " Arsenious acid, when 
it produces the death of a part, does not act, strictly 
speaking, as an escharotic ; it destroys the vitality of 
the organized structure, and its decomposition is the 
consequence. The true escharotic acts chemically, 
producing a decomposition of the part to which it is 
applied, — a state incompatible with life." Pereira 
says : " Though employed as a caustic, yet the nature 
of its chemical influence on the animal tissue is un- 
known ; hence it is termed by some a dynamic 



TREATMENT OF SENSITIVE DENTINE. 285 

caustic." Its escharotic power certainly bears no 
proportion to its devitalizing power; but it is pro- 
bable that it forms definite compounds with some of 
the constituents of living tissue ; and if so, these 
compounds appear to be readily and rapidly decom- 
posed, so that the acid becomes again free to attack, 
with similar results, the subjacent parts. The topical 
application of arsenic is liable to be followed by con- 
stitutional effects. 

All dentists are aware of the fact that a tooth-pulp 
may be destroyed by arsenic, through a wall of con- 
siderable thickness. To accomplish this, the agent 
must in some way penetrate the substance of the 
dentine, and its vitality is destroyed so far as it is 
thus penetrated; indeed, the vitality of the whole 
crown of the tooth, both dentine and pulp, is often 
destroyed by the use of this remedy, applied even 
to a small cavity. Exalted sensibility of dentine is 
subdued by this agent, more by its devitalizing than 
through its chemical energy. It is soluble in creosote 
and similar oils, and to a considerable extent in 
alcohol and water. It is absorbed much more rapidly 
when applied in solution than in solid ; and the more 
vascular the dentine, the more rapid and extensive 
will be the absorption ; and on this account there is 
great risk in applying it to the teeth of young per- 
sons, or to any teeth that are highly wanting in den- 



286 PATHOLOGICAL CONDITIONS. 

sity; indeed, it will destroy the vitality of very dense 
teeth. The manner in which it passes into the den- 
tine is not very definitely understood. It is very 
certain, however, that in more highly organized parts 
it is carried through by the circulation, and also may 
be taken up by imbibition. In either of these ways 
it may pass into the dentine, and so far as concerns 
the results, it matters not in which way. It is 
enough to know that there are well-defined cases of 
its specific effect on the constitution, after having 
been applied to dentine, demonstrating that it must 
have been taken up by the circulation ; and also cases 
of its manifest effect on the periosteum in a short 
time after having been applied to the cavity of a 
tooth the pulp of which is dead — thus proving that 
it must have been absorbed by imbibition. 

If arsenic is ever employed in the treatment of 
sensitive dentine, it should be suffered to remain in 
the cavity but a short time, — from one to three 
hours, — and then the part with which it was in con- 
tact should be very thoroughly excavated. In decid- 
ing in what cases it is proper to use it, there is need 
of careful discrimination as to the tooth's structure 
and density, for injurious results have sometimes 
followed its application, notwithstanding the utmost 
care ; if it has once been absorbed by the dentine, 
antidotes will avail nothing. On the whole, there- 



TREATMENT OF SENSITIVE DENTINE. 287 

fore, it is better to refrain from its use altogether in 
the treatment of sensitive dentine. 

AlJcaline caustics have been to some extent used for 
the treatment of this affection. A preparation made 
after the following formula is said to relieve some 
cases very promptly : Take Canada balsam and 
slacked lime, and having made them into a paste, fill 
the cavity partially full with it, and permit it to re- 
main until the object is accomplished. 

The sensitiveness of dentine may be obtunded by 
friction on the affected part with a smooth burnisher. 
This method, however, is applicable only to those 
cases in which there is room to use the instrument. 
On the surfaces of the teeth, where there may be 
sensitiveness, it is very applicable and very efficient. 
Simple pressure, without friction, it is suggested, 
will accompKsh the same object, though pressure and 
friction combined are doubtless more efficient. 

During the last three or four years, various appli- 
cations have been introduced, and used to greater or 
less extent, for the relief of sensitive dentine during 
the operation of filling. Moistening a cavity with 
creosote, carbolic acid, carvacrol, or oil of cloves, at 
the time of operating, and especially in excavating, 
will in many instances greatly mitigate the pain, and 
in some relieve it altogether. 

About two years ago, a nostrum denominated 



288 PATHOLOGICAL CONDITIONS. 

"Dental Pain Obtunder" was introduced, and used 
by many in the profession, and in many instances 
with decidedly good results. With it, however, as 
with many other things, there was a variety of 
opinions and experiences. 

The use of any of these things, even though they 
would in any case give temporary relief, do not meet 
the difficulty in a proper manner, except in those 
cases in which the affection is very superficial ; in 
every other case the aim should be complete restora- 
tion to a normal condition, and this, for the most part, 
at least, must be accomplished by nature, aided, so 
far as practicable, by proper systemic and local treat- 
ment. 

Many suppose that if they can by any temporary 
obtunding of sensibility introduce a filling, all will be 
well. This often proves to be a serious mistake, for 
when a filling of metal is placed on sensitive dentine, 
the thermal changes very often prevent a return to a 
normal condition, and in some cases greatly increase^ 
the difficulty. In all instances, so far as possible, an 
entire restoration to a state of health should be 
effected before filling, or the part shielded by a non- 
conductor. 



CHAPTER IX. 

EXPOSED PULPS. 

When the pulps of the teeth are exposed, it is 
usually in consequence of decay, but sometimes of a 
gradual wearing down of the organs in mastication, 
in other cases by chemical abrasion. When the pulp 
of a tooth is found exposed, the course of remedy to ' 
be pursued will be indicated by the following con- 
siderations : — 

1st. The constitution and the vital energy of the 
system. 

2d. The condition of the mouth and teeth. 

3d, The condition of the pulp. 

4th. The size of the orifice at which it is exposed. 

5th. Whether the exposure is of recent or of re- 
mote origin. 

6th. If in a tooth of more than one root. 

7th. The position of the tooth in the mouth, and 
that of the decayed cavity in the tooth. 

The propriety of attempting to preserve the vitality 
of the pulp after exposure has been questioned. Some 
take the position that after the development and for- 



290 EXPOSED PULPS. 

mation of the tooth, the pulp is no longer of any use, 
and may, without damage, be dispensed with ; while 
others maintain that when the pulp is destroyed, the 
tooth is no longer of any value. The truth is perhaps 
a medium between these extremes. The pulp of the 
tooth is valuable in the economy, or nature would 
dispense with it. Analogy teaches that it would not 
be retained longer than it could subserve some bene- 
ficial purpose. But it is also true that a tooth may 
be retained and perform its proper function for a long 
time after the destruction of its pulp, notwithstand- 
ing it is in a less perfect condition; though it is 
always desirable to preserve the life of the tooth 
when practicable, for the crown depends on the pulp 
for its vitality, and living dentine presents more re- 
sistance to decay than dead ; besides, a dead tooth 
never exhibits the bright, life-like appearance of a 
living one. The parts about a dead tooth, too, are 
far more liable to disease than those about a living 
one. These are only a few of the considerations 
for retaining the pulps of the teeth. 

It has been maintained that the structure of the 
tooth-pulp is of such peculiar character, and so sus- 
ceptible of diseased action, that after it has . become 
affected, though but slightly, it cannot be restored 
to a healthy condition. We see no ground, however, 
for such an assumption, except it be in the imperfect 



TREATMENT OF EXPOSED PULPS. 291 

treatment which this organ so frequently receives ; 
for the fact of its delicate structure does not neces- 
sarily imply an impossibility of restoring it from 
disease. The pulp of the tooth is endowed with such 
functions as ordinarily render living tissues suscept- 
ible of treatment for abnormal conditions, such as 
circulation, nutrition, absorption, and a distribution 
of nerves. The success attending the methods of 
treating exposed pulps practiced by the dental pro- 
fession during the last few years is a source of more 
encouragement than a thousand theories. 

Treatment of Exposed Pidps. — In cases where the 
conditions are favorable. — the constitution good, the 
pulp but recently exposed at a small orifice, and in a 
healthy condition, — treatment may be instituted 
with almost absolute certainty of success. If there 
is no inflammation or irritation, therapeutic treatment 
is not indicated ; but the decay should be removed 
and the cavity formed without wounding the pulp, if 
possible ; though a slight wound is of no serious 
consequence, for immediately after the hemorrhage 
ceases, the operation may proceed as though the pulp 
were intact. There have been suggested various 
methods for protecting the pulp in cases of this kind ; 
formerly, the capping of pulps was very extensively 
practiced, by which a shield was thrown over the 
exposed point, so as to prevent the filling from coming 



292 EXPOSED PULPS. 

in contact with it. Various materials have been 
suggested and used for caps ; but gold and lead were 
formerly used for this purpose, especially when the 
object was to form an arch over the point of expos- 
ure. These caps are cut out of thin gold plate, or 
thick sheet lead, of the proper shape and size, and 
stamped with a convex punch, thus receiving such a 
concavity as fits them for covering the exposed pulp 
without touching it. A little groove, of depth suffi- 
cient to hold the cap, and prevent it from being dis- 
placed by the introduction of the filling, may be made 
in the dentine all round the orifice of exposure. The 
cap is then to be adjusted to its position in the 
cavity, having been previously touched round its 
edge with adhesive wax; the filling is then intro- 
duced in the usual manner, carefully, so as not to 
displace the cap ; and if this is of lead, great caution 
is to be observed in condensing the filling above it, 
since it will be easily compressed. 

The therapeutic influence of lead on exposed pulps 
is supposed by some to be definite and decided ; but 
though lead is a less perfect conductor of heat, and 
in this respect is better than gold, and though, in the 
capacity of a pulp-cap, its indestructibility is probably 
quite sufficient, yet, if no change takes place in it, it 
is not very apparent how it exercises any therapeutic 
action on the pulp. Experience, however, proves 



TREATMENT OF EXPOSED PULPS. 293 

that the success is quite as good in the use of lead 
caps as in those of gold ) and the former are more 
easily applied. 

Another method of shielding an exposed pulp is, to 
form an arch over it by the filling. This operation is 
performed by beginning the filling at that side of the 
cavity most easily approached, building on the gold 
from the points of its attachment almost to the point 
at which the pulp is exposed, and then attaching 
from one point to another without permitting the 
gold to come in contact with the pulp. Care should 
be taken that the gold present as smooth a surface 
to the pulp as possible. When the orifice of exposure 
has been well covered and protected, the remaining 
portion of the cavity is filled as usual. This method 
of forming a protection over a tooth-pulp possesses no 
advantage over the ordinary cap; and being much more 
difiicult, it is impracticable in any but skillful hands. 

This practice with exposed pulps, however, has 
within the last few years been almost wholly aban- 
doned, for the following reasons : because it so fre- 
quently failed to accomplish the object, and because 
a better method of treatment has been discovered. 
It was found that, under that practice, many cases 
which at first promised well did not preserve the life 
of the pulp, though the fatal results were not always 
immediate — a year or two. and in some instances a 



294 EXPOSED PULPS. 

much longer period, intervening between the ope- 
ration and the death of the tooth. In favorable 
cases, the pulp, even after exposure, will, if protected 
from the influence of foreign substances, throw out a 
bony deposit, and even close up an orifice of expos- 
ure, thus forming for itself a natural shield. It is 
suggested that the capping operation is not the best 
protection for facilitating this process. It is probable 
that in some cases the space between the cap and 
the pulp, though it were large, would be filled with 
lymph ; and even if it were thus filled, a bony deposit 
might not be made ; and if it were not, it could not 
fail ultimately to prove injurious to the pulp. But if 
the space should not be filled with lymph, the diffi- 
culty would be equally as great, since the pulp would 
protrude through the vacuum beneath the cap, and 
necessarily become diseased, since it would be irri- 
tated by its contact with, and its pressure against, 
the sharp edges of dentine at the orifice of the cavity; 
and it may remain thus diseased for a long time, or 
die at once. Thus it is, no doubt, that the great 
majority of failures occur under this kind of treat- 
ment. In order to obviate this difficulty, it has been 
suggested that the space under the cap be filled with 
some appropriate substance, as a thick solution of 
gutta-percha and chloroform, or a small pledget of 
cotton saturated with collodion. 



TREATMENT OF EXPOSED PULPS. 295 

The frequent failures which occur in capping pulps 
have incited the profession to seek some other method 
of treatment. A vacuum above the pulp being objec- 
tionable, some suitable material is employed as a 
shield for this, being placed on the orifice of expos- 
ure, in contact with the pulp ; and the filling is then 
introduced without pressure upon the point of ex- 
posure. There are several substances that have 
been thus employed, the chief of which are asbestos, 
oiled silk, collodion, gutta-percha, Hill's stopping, 
and OS artificial. The material for this purpose 
should be a non-conductor of heat, should not be 
subject to decomposition when in contact with the 
pulp, and should present a smooth surface and be 
easily adapted. In shielding a pulp in this manner, 
it is important that pressure be not made upon it ; 
and there is not much liability to this, where the 
orifice of exposure is small, but where it is large, 
much care is required in the introduction and con- 
solidation of the plug. The opinion has been enter- 
tained by some that the pulp of a tooth will not tole- 
rate any foreign substance in contact with it; but 
facts refute such an opinion. By this kind of protec- 
tion for a pulp, secondary dentine is more likely to 
be developed. 

A very perfect covering for an exposed pulp may 
be made by dropping on it a little collodion or solu- 



296 EXPOSED PULPS. 

tion of gutta-percha, and after the evaporation of the 
ether or chloroform filling over it. This method has 
the advantage of completely filling and occupying 
the space, and exactly conforming to the part, which 
is an important requisite in this operation. When 
the exposure is at a large orifice, if the pulp is 
healthy, and the constitution of the patient good, the 
same general course of treatment may be adopted, 
except that more care and skill will be necessary in 
the performance of an operation. Indeed, it is 
difficult to make a good operation in cases of this 
kind, using for the covering only a soft or flexible 
material. 

A method of operating that is probably more effi- 
cient than any other, is to prepare the cavity as 
already directed, place on the pulp two or three 
drops of collodion or solution of gutta-percha, letting 
it partially stiffen, and then over this fit a gold or 
lead cap as exactly as possible, so that it shall rest 
on the solid dentine, far enough from the orifice of 
exposure to preclude it from injurious influence on 
the pulp. On this, the filling is introduced as usual, 
care being had not to displace the cap, which in all 
cases should have a seat made for it, formed at the 
time of the preparation of the cavity. 

When the pulp of a tooth becomes, by exposure, 
inflamed or diseased, some more special treatment is 



TREATMENT OF EXPOSED PULPS. 297 

indicated, and usually it is therapeutic. In every 
such case, the treatment will contemplate either the 
preservation of the pulp, when the circumstances will 
warrant ; or when they will not, then its destruction 
and removal. The former of course is always to be 
preferred, where practicable. Some of our best ope- 
rators very strongly denounce the wholesale destruc- 
tion of the pulps of the teeth, practiced by many; 
while some dentists never attempt to restore and pre- 
serve them at all, how^ever slightly diseased. This, as 
elsewhere intimated, is an erroneous practice; for there 
is no obvious reason why the pulp of a tooth may 
not be restored from disease to health as readily as 
other parts, endowed as it is with circulation, nutri- 
tion, absorption and the distribution of nerves. The 
particular kind of treatment required in any given 
case, however, will be controlled by various circum- 
stances, such as the nature and extent of the disease, 
whether it is of chronic or acute tpye. When the 
irritation or inflammation is but slight, and is kept 
up solely by the contact of irritating substances, res- 
toration of the pulp may be effected by a removal of 
these irritating causes, and protection of the pulp 
against their further influence : in such case, nature, 
unaided, affects the restoration. In a feeble consti- 
tution, the pulp, though but slightly affected, will 
require topical therapeutic treatment ; and meanwhile 



298 EXPOSED PULPS. 

general treatment may be employed to give increased 
tone to the system. In the local treatment, neutral- 
izing agents should be applied first, and afterwards 
such as will counteract and reduce inflammation, 
especially if this is in an active state. But if the 
pulp is in a morbid condition, with retarded circula- 
tion and a tendency to enlargement, active and stimu- 
lating applications will be indicated, and in some 
cases escharotics, such as nitrate of silver, chloride of 
zinc, and chromic acid, the latter especially where 
there is a tendency to prurient enlargement of the 
pulp. The therapeutic principles embraced in astrin- 
gents, tonics, stimulants, and escharotics, are mainly 
to be relied upon in the topical treatment of exposed 
pulp. 

The length of time requisite for this treatment will 
vary with different cases. In the case of a recent 
acute inflammation, the process of restoration may be 
completed in two or three days ; while in other cases, 
where the difficulty is of long standing and of a more 
complex character, it will require from a week to two 
months. The systemic condition of the patient also 
exercises a great modifying influence upon the treat- 
ment. Leeching and counter-irritation of the gums 
are sometimes resorted to in this treatment ; but it is 
rare that any definite beneficial result ensues. De- 
pletion of the pulp itself may often be practiced with 



TREATMENT OF EXPOSED PULPS. 299 

decided success : and it may be accomplished either 
by puncturing the pulp with a fine-pointed instru- 
ment, or by excising a small portion of it at the ori- 
fice of exposure, in either case avoiding laceration. 
By this means the distended vessels are relieved ; 
and in many cases, where the difficulty is but slight, 
immediately after such relief by puncturing, so soon 
as the hemorrhage has ceased, the tooth may be 
filled. But if the depletion is by excision, time must 
be allowed for the recovery of the incised surface — 
ordinarily from three to ten days. 

A method of treatment of exposed pulps — first 
introduced to the notice of the profession by Dr. 
AUport, and one which in his hands has proved quite 
successful — consists in the excision of a portion of 
the pulp at the orifice of exposure, drawing the 
edges of the incised part together, and inducing their 
union, and in this manner closing the wound, when 
less space is occupied by the pulp than before the 
operation. After securing this result, the operation 
of filling the tooth may be performed ; the same care 
being observed, however, as already suggested in 
cases of exposed pulp. 

The employment of pepsin has been quite effective 
in the hands of some practitioners. The method of 
application is as follows : with the pure pepsin in 
powder, and diluted hydrochloric acid, or liquid pep- 



300 EXPOSED PULPS. 

sin, form a paste of creamy consistence, that can be 
readily applied to an exposed pulp. 

The cases in which this preparation seems appro- 
priate and efficient are those in which there is 
debris and offensive matter in contact with and irrita- 
ting the pulp that cannot be readily removed, either 
with an instrument or by washing. There is often a 
film of partially devitalized pulp substance upon and 
covering the exposed part, that operates as an active 
irritant to the tissue beneath it ; this and all similar 
substances are dissolved and removed by the action of 
the pepsin paste ; and not only is this accomplished, 
but the pulp is stimulated to a healthy action. 

For the application the cavity through which the 
exposure is effected should be cleaned thoroughly and 
dried ; then place a drop of the paste on the point of 
exposure, on this put two or three plies of bibulous 
paper, then fill the cavity with wax, softened by 
heat, so that its introduction will not cause pressure 
upon the pulp. This should remain for from six 
to twenty-four hours, when it should be removed ; 
the pulp will usually now present, at the orifice of 
exposure, the bright pinkish hue of the healthy 
tissue ; very seldom will a second application be 
required. 

This condition being attained, the pulp is ready 
for its covering for permanent protection. 



TREATMENT OF EXPOSED PULPS. 301 

For the proper covering and filling over an exposed 
pulp, certain indications must be fulfilled : 

First. A material must -be used that will be accep- 
table to the tissue, that will in no degree irritate it. 

Second. It should be a substance that will not 
decompose or undergo change when in contact with 
the pulp. 

Third. It must be a material of such consistence as 
to be made easily to occupy all the space at the ori- 
fice of exposure, and yet make no pressure upon the 
, pulp. 

Fourth. It should be a non-conductor of heat equal 
to or beyond the dentine. 

Fifth. It should possess sufficient resistance to 
admit the proper introduction of the best material 
for filling. 

Thus it is apparent that the aim is, and should be, 
to place the exposed pulp back again in as nearly its 
normal state of closure as possible. This is the 
criterion that should guide in the performance of this 
most delicate operation. 

A very good method of accomplishing this was 
suggested by Dr. J. S. King about the year 1871. 
Others have claimed that they had used the same 
principle before. 

It consists in placing in the orifice of exposure and 
on the pulp, after it has been freed from all irritants 



302 EXPOSED PULPS. 

and restored to a state of health as nearly as possible, 
a paste of oxyd of zinc and creosote of a thick creamy 
consistence ; with this the orifice should be completely 
covered ; remove any excess of creosote with bibulous 
paper ; then cover this, and fill the cavity of decay 
with OS artificial or Guillois' cement. So far as the 
pulp is concerned, this is to be the permanent cover- 
ing; as to the cavity of decay, this may constitute 
the permanent filling, or sufficient of the os artificial 
may be cut away from the cavity to enable it to be 
well filled with gold, or any other material. This in 
the hands of many has proved a very successful 
method of enclosing exposed pulps. 

The formation of secondary dentine, by which the 
orifice of exposure is closed up, has already been re- 
ferred to ; and it has been suggested that treatment 
to facilitate this process may be instituted. With a 
view to this, temporary fillings are sometimes intro- 
duced. If a shield of secondary dentine is desirable 
before permanent filling, the best method of securing 
it is, after seeing that the general recuperative power 
is in the best condition, to place in the cavity a tem- 
porary filling, of such material and in such manner as 
will be most acceptable to the pulp, and then leave 
nature to accomplish the work. In many cases, 
especially in young persons, this process would be 
facilitated by an administration of bone phosphate. 



TREATMENT OF EXPOSED PULPS. 303 

The pulps of the teeth of the young are more diffi- 
cult to treat successfully than those of the more 
advanced in life. 

A method of treating exposed pulps with a view of 
securing a closure of the orifice of exposure by 
nature, was first suggested and practiced in 1873 by 
Dr. J. E. Cravens, and consisted of the following 
treatment : 

The exposed pulp should be rendered as nearly 
absolutely free from extraneous matter as possible, 
but softened or partially decalcified dentine should 
remain undisturbed in the cavity. The cavity should 
be secured against moisture, and kept so during the 
operation ; being thoroughly clean and dry, the pulp 
exposure should be covered with a paste prepared as 
follows : Upon a warm slab of ground glass put a 
drop of Merck's lactic acid ; add twice that volume 
of magma, or freshly-precipitated phosphate of lime ; 
then rub till a complete solution is effected. This is 
lacto-phosphate of lime. To this solution add dry 
phosphate of lime until the paste is of proper consist- 
ence for application. Place this paste directly on 
the exposed pulp so as to occupy all the space, and 
yet make no pressure upon it; the cavity may be 
filled from one-fourth to one-third full of this mate- 
rial ; then remove the moisture from the surface of 
the paste with spunk or some absorbent, then cover 



304 EXPOSED PULPS. 

it with two or three plies of bibulous paper, cut to fit 
the cavity and moistened with sweet oil ; press this 
carefully upon the paste, especially all round the 
border ; then cover this and fill the cavity with os 
artificial, or its equivalent. Hill's stopping or gutta- 
percha cannot with safety be used instead of the os 
artificial, as more or less pressure would be occasioned 
by their introduction. Dr. Cravens suggests that 
the pulp should not be treated previously with any- 
thing that would coagulate albumen, and indeed 
should have no preparatory treatment except that 
already referred to. 

This dressing and filling should remain undisturbed 
for from two to six weeks, and one application is 
usually quite sufficient to induce bony deposit to fill 
the orifice of exposure and cover the pulp. 

Pain will seldom be experienced after the applica- 
tion of the phosphate of lime as above described, but 
if it should, the use of sedative treatment, either lo- 
cally or through the system, will meet the difficulty. 
In no case should the dressing and filling be removed 
or disturbed till the allotted time has elapsed. Dr. 
Cravens entertains the opinion that the phosphate of 
lime, thus applied, is appropriated in the formation of 
the new deposits, and that thus the living tissue 
beneath has cooperation in this process, at least so far 
as supply is concerned. 



REMOVAL OF PULPS. 305 

Destruction of the Pulp. — There are cases in which 
an attempt to restore the pulp, even when recently 
and but slightly diseased, would prove unavailing ; so 
feeble is the vitality that it is destroyed at almost 
ih^ first touch. Two cases in apparently the same 
condition pathologically, but in different constitu- 
tions, will, under the same treatment, exhibit very 
different results. A pulp in a system with low vital 
power, that is highly diseased, is but seldom, if ever, 
under any circumstances, susceptible of restoration; 
and in such case, of course, devitalization and remo- 
val are indicated. This was formerly supposed to be 
(•lU impracticable operation, for two reasons : first, 
because it was very difficult and painful \ and second, 
because of the consequences likely to ensue. Then, 
the operation was attempted only on teeth having 
one root, and those of cylindrical form ; but now, it 
is performed successfully on all classes of teeth. 
When destruction of the pulp is decided upon, such 
means should be employed as will effect the object 
promptly and thoroughly. Everything should be 
entirely removed from the pulp-chamber and the 
canal of the root, for any remaining portion is liable 
to induce inflammation and suppuration ; and alveolar 
abscess also frequently ensues. 

There are two methods of destroying the pulp : 
the one, by an operation ; the other, by the applica- 



306 EXPOSED PULPS. 

tion of some devitalizing agent. The choice of these 
methods will be governed by circumstances, such as 
the temperament of the patient, the condition of the 
tooth and parts about it, and the class of the tooth to 
be operated upon. For patients of a nervous, irri- 
table temperament, to whom a removal of the pulp 
by an operation would occasion great pain and a 
severe shock, it would be better to apply some agent 
to destroy the vitality of the pulp, and then remove 
it ; but, on the contrary, where there is vigor, and a 
capacity of endurance, it is preferable to remove the 
pulp at once by an operation. To accomplish this, 
there are two or three methods of manipulation. In 
the first place, however, by whatever method it is 
removed, it should be fully exposed ; the orifice of 
exposure should be as large as the pulp-chamber, 
and the entrance as nearly as possible on a line with 
the tooth's axis ; hence it will be necessary in many 
cases to make an opening into the pulp-chamber at a 
point different from that of the opening caused by the 
decay. For instance, in the incisor teeth, when the 
decayed cavity is small, on the side, near the margin 
of the gum, penetrating to the pulp-chamber, and 
exposing the pulp, the entrance through this opening 
into the canal will be almost at right angles with it ; 
and in such case it would be impossible, through this 
opening, to manipulate freely in the root, and it 



REMOVAL OF PULPS. 307 

would be necessary to make an opening with a drill 
through the palatal portion of the tooth directly into 
the canal and on a line with it, which opening should 
be large enough readily to allow of a removal of the 
pulp through it, and of an unimpeded performance of 
all the subsequent operations in the canal of the root. 
After the pulp has been exposed by the proper 
opening, the instrument should be selected for its re- 
moval. There are different forms of instruments for 
this purpose. Some operators employ the untem- 
pered, four-sided, barbed broach, thrusting it into the 
canal as far as possible, then turning it two or three 
times around, and thus wrapping the pulp round the 
instrument, when both are drawn away together. 
This method always occasions considerable pain. 
Others employ simply the three or four-sided broach, 
thrusting it through the pulp all the way up the 
canal, and thus lacerating it and breaking up its 
structure, so that it may afterward be removed with- 
out much pain. Another method, and one which 
seems preferable to all the others, is as follows : 
Take a very fine untempered steel wire, round and 
smooth, not larger than 34 to 36 of Stub's gauge- 
plate ; flatten the extreme point, and turn it to 
an angle of from thirty to forty degrees ; place 
the end of this against one wall of the canal 
at the point of exposure of the pulp ; press it 



308 EXPOSED PULPS. 

steadily up the canal, with its edge bearing against 
the wall, as far as it will go, and then twirl it sud- 
denly round. Thus an incision is effected near the 
point of the root, when the pulp with the instrument 
may be drawn away together; or, if not thus re- 
moved, it may be caught with some fine point, and 
removed with little or no pain. This manner of 
introducing the instrument, too, causes less pain than 
either of the others, for there are no sharp edges or 
points presented in passing the instrument up the 
canal, to cut or lacerate the pulp. In the removal 
of the pulp from the teeth of young persons, care 
should be taken lest the instrument pass entirely 
through the foramen, at the apex of the root ; but 
with adults there is little or no danger of such an 
accident. 

The directions here given would be quite sufficient, 
if closely followed, for the removal of the pulps of the 
six anterior superior teeth. For the removal of the 
pulps from the bicuspids, the entrance can ordinarily 
be effected through the decayed cavity. Usually 
there is some lateral compression of the roots of these 
teeth ; and the canal through the root corresponds in 
its formation, so that it represents a mere fissure, 
expanded a little on each side of the centre. It is often 
difficult, and requires very delicate manipulation, to 
remove all the pulp from these fissures. A very fine 



REMOVAL OF PULPS. 309 

instrument may be pressed down each side, and yet 
a portion of the pulp remain in the centre. This dif- 
ficulty is most fully presented in those cases in which 
there has been an apparent, though abortive, effort 
of nature to produce two roots. 

The removal of the pulps of the molar teeth is a 
more extensive and complicated operation. The pulp 
to be operated upon should be fully exposed, the 
orifice of exposure being made as nearly as possible 
of the size of the pulp-chamber ; and the instrument 
to be used should be such as last described, except 
that it should be much larger, and is to be intro- 
duced, in the same manner, to the bottom of the 
pulp-chamber, and rotated suddenly, so as to cut off 
the ramifications of the pulp into the roots, thus at 
one sweep dislodging the entire body of it without 
laceration. The practice of plunging a large barbed 
or cutting instrument into the pulp of a molar tooth 
is painful in the extreme. 

The pain of removing the living tooth-pulp may be 
much mitigated in all cases, and in many prevented 
altogether, by the use of local anaesthesia. This may 
be effected by the application of chloroform, or some 
one of the various anaesthetics that are available, 
directly to the pulp. The application of cold is quite 
efficient ; this may be effected by the use of ether 
spray or ice. So extended have become the facilities 



310 EXPOSED PULPS. 

for inducing local anaesthesia, that the spray or ice 
need hardly be employed. 

The branches of the pulp in the roots should be 
removed in the manner already directed for the re- 
moval of the pulps from teeth of single roots. The 
palatal root is very easily operated upon ; but as to 
the buccal roots, there is frequently encountered the 
same difficulty referred to in speaking of the bicus- 
pids. When a pulp is removed in this manner, the 
wound commonly heals by first intention, and there 
is formed a permanent cicatrix. 

Actual Cautery. — For destroying tooth-pulp, the 
actual cautery was formerly employed to a conside- 
rable extent, and was at one time a favorite method 
with French dentists. This consists in heating a 
wire of proper size to a white heat, and thrusting it 
into the canal of the root to the apex, the object 
being to destroy the pulp the instant the wire comes 
in contact with it. The operation requires much 
skill, and is attended with many difficulties. It is 
fraught with terror to the patient ; if the temperature 
of the wire is not at white heat at the time of its 
insertion, the pain of the operation is most intense ; 
it is liable to leave the parts in such a condition as 
often to induce inflammation and suppuration, which 
may involve the investing membrane and the sur- 
rounding parts. Besides, by this method, the object 



REMOVAL OF PULPS. 311 

is, at best, no more successfully attained than by 
others. 

The galvanic cautery has been employed to some 
extent in general surgery, and it is very probably 
the best form in which the actual cautery can be 
applied for destroying pulps of teeth. 

Potential Cautery. — This term is applied to those 
therapeutic agents which destroy vital tissue by 
establishing a condition incompatible with vitality. 
Many preparations have been employed as topical 
applications to devitalize the pulps of teeth, but only 
two or three to any considerable extent. A conside- 
ration of the nature and something of the specific 
action of these agents may not here be out of place. 
And first, of 

Arsenious Acid. — This has been more used, topi- 
cally, for the destruction of tooth-pulp than all other 
applications. The first account we have of its use for 
this purpose dates back to 1836, when it was applied 
by Dr. Spooner, though others claim to have em- 
ployed it about the same time. The specific action 
of arsenious acid on vital tissue is not well under- 
stood. It is supposed by some that it forms a com- 
pound with some element of the tissue, and in this 
way destroys the vitality. 

Any such combination, however, has hitherto 
escaped detection; and it is certain that if a com- 



312 EXPOSED PULPS. 

pound is formed, it is not fixed or permanent in its 
character, since the arsenic will be carried to different 
parts of the system, and its specific influence mani- 
fested wherever it goes, which could not be the case 
if it formed a fixed compound. The more probable 
theory is that it destroys vitality by its influence on 
nerve tissue, producing such a change in its structure 
as to arrest its function at once. In reference to the 
action of this agent upon living tissue, much investi- 
gation remains to be made. Animal tissue takes it 
up by imbibition ; and it is also absorbed by the cir- 
culation, and conveyed by it, as already suggested, 
throughout the system. Frequently, however, it is 
applied to living tissue, under conditions that prevent 
such absorption. It is often employed in the treat- 
ment of carcinoma. In the application of arsenious 
acid to the pulps of teeth, for their destruction, seve- 
ral circumstances are to be considered, such as the 
age of the patient, the constitutional tendency, the 
vascularity of the dentine. Where the vascularity is 
great, the utmost caution is required. The indis- 
criminate use of this agent in the teeth of the young 
is attended with great risk. Some constitutions are 
peculiarly susceptible to its influence, experiencing 
its effects even in remote parts of the system, after 
its application only to the pulp of a tooth. It is 
soluble in creosote and most of the essential oils, 



LZV V 1 J ?ZL?S. 313 

and to some extent in alcohol and water. In manv 
eases when it is applied to the pnlp of a tooth, more 
or less disturbance of the periosteimi is exhibited a 
short time after — ^in some instances in a few hourSj 
and in others after several daTs. thus srivinor evi- 
dence that it has bj some means come in contact 
with the periosteum. Its influence on this will often 
be manifested under percussion, in advance of any 
other symptom. 

Application. — There are two or three methods of 
applying arsenious acid for the destruction of the 
pulps of teeth. The ordinary arsenic of commerce is 
used. It was formeriy employed very extensively in 
connection with sulphate of morphia, mixed in equal 
parts, and applied to the pulp with a small pledget 
of cotton, moistened with creosote or some essential 
oil, the former being most frequently used. AlcohoL 
ether, or water may be employed instead of creosote, 
and in some respects and in some cases would be 
preferable. The pledget of cotton, thus prepared, is 
introduc-ed into the decayed c-avity, with the prepa- 
ration in contact with the exposed pulp. Another 
pledget of cotton, saturated with a thick solution of 
gimi sandarac and alcohol, or gutta-percha and chloro- 
form, is placed over this in the cavity, to prevent the 
escape of the preparation, or the entrance of moisture 
or foreign substances. Any prejiaration may be used 



314 EXPOSED PULPS. 

that will accomplish these objects. In the applica- 
tion of the pledget, care must be exercised lest too 
much pressure be made on the pulp, and pain be thus 
produced. In order to prevent this pressure, another 
method has been adopted, which consists in forming 
a cap of lead, placing it in the arsenic, in the dry 
state or with some suitable solvent, and then fitting 
it over the exposed pulp, and retaining it there with 
a pledget of cotton, as above, or with Hill's stopping, 
gutta-percha, or adhesive wax. Thus the preparation 
comes gently in contact with the pulp, and prevents 
any pressure on it. ' The morphine is used for the 
purpose of diminishing the pain which frequently 
results from the application of arsenic only ; but its 
influence for such a purpose is predicated more on 
theory than on practice ; for facts prove that, applied 
to living tissue, it produces pain rather than allays 
it. Therefore the more observing and better class of 
practitioners have discarded it. 

Other substances have been mixed with arsenic, 
for the purpose of mitigating or altogether relieving 
the deleterious consequences so liable to follow its 
administration ; as, for instance, pulverized charcoal, 
which, combined with it in equal parts by weight, 
makes a favorite preparation with some practitioners, 
by whom it is claimed that the charcoal counteracts 
the specific effect of the arsenic on parts other than 



KEMOVAL OF PULPS. 315 

those for which it is directly designed. But this 
theory, in the light of any elucidation yet given, is 
very vague. The claim cannot be that charcoal is an 
antidote to arsenic, since facts refute it; for if it 
were, the arsenic of the preparation, when applied to 
the pulp of a tooth, would fail of its effect, because 
the charcoal being also in contact with the pulp, 
would there, if ever, counteract the poison. But this 
it does not do, for the pulp is destroyed about as 
readily by this preparation as by arsenic alone. And 
if when the arsenic and charcoal are thus together no 
counteracting influence of the latter is manifest, 
much less will there be any when the arsenic, 
escaped from the charcoal, runs riot through the tis- 
sues, whither the latter cannot follow. The only 
probable advantage, then, of this preparation is, that 
the arsenic is not taken up from it by the tissues 
so rapidly as when it is applied alone, or with any- 
thing that is soluble with it ; for when thus applied, 
the whole is very soon dissolved, and taken up by 
the pulp and dentine. But when combined with 
charcoal or the like, little more of the arsenic is 
absorbed than that which comes in contact with the 
pulp. Hence the conclusion that the influence of the 
charcoal is mechanical, and not therapeutic. 

This preparation is better applied perfectly dry, 
beneath a lead cap, which should completely close 



316 EXPOSED PULPS. 

the cavity. Any other material that would mix as 
readily with the arsenic, without being soluble, and 
that would not induce irritation when in contact with 
the pulp, would be quite as good for this purpose as 
charcoal. Irritating gases generated in a tightly- 
closed cavity are absorbed by charcoal. 

Cobalt, in which the active principle is arsenic, 
has been extensively used for destroying pulps ; but 
it is in no respect superior, and in some respects it is 
probably inferior, to the preparation of charcoal and 
arsenic ; it is applied in the same manner. 

The length of time the preparation should remain 
in the tooth will be determined by the condition of 
the pulp when it is applied, the age of the patient, 
the vascularity of the dentine, the susceptibility of 
the patient to the influence of arsenic, and like cir- 
cumstances. It will usually be from three to twenty- 
four hours. In some cases a very small particle will 
thoroughly accomplish the work, while in others a 
much larger quantity may remain in contact with the 
pulp even for a much longer time, without producing 
more than a superficial result. And cases occasion- 
ally occur in which it seems almost impossible to 
destroy the vitality of a pulp with arsenic. A case is 
on record in which the pulp was first fairly exposed 
in a superior bicuspid tooth, the health and constitu- 
tion being good, and the temperament sanguino-lym- 



REMOVAL OF PULPS. 317 

phatic ; and arsenic with morphine was applied to it, 
directly, five times within ten days, without pro- 
ducing any apparent effect ; then an application of 
creosote and tannin was made three or four times, 
during as many days ; afterward the tooth was tem- 
porarily filled with gutta-percha ; and finally, in ten 
or twelve days, this filling being removed, the pulp 
appeared in a perfect state of preservation and health, 
with all the indications of undiminished vitality. 
Over the exposed point there was placed a non-con- 
ductor, and upon it a filling of gold, and one year 
after, the tooth presented the appearance of perfect 
life and health, having given the patient no annoy- 
ance during the whole period. 

Hence, it is quite obvious that there is a great 
diversity of susceptibility to the influence of arsenic, 
and that the study of these idiosyncrasies is both 
interesting and valuable. The occurrence of injurious 
consequences from the use of arsenic has induced 
many operators to abandon it altogether. But these 
injurious results perhaps occur always either through 
mal-administration or from a peculiar susceptibility 
to the influence of the drug, and a superior skill and 
a more accurate diagnosis would avoid them almost 
entirely. After the desired result with arsenic has 
been obtained, it has been thought that antidotes to 
arrest its further operation might be made available. 



318 PULP-CAVITIES. 

The hydrated sesquioxyd of iron is one of the best 
antidotes to arsenic, and has been used in the teeth 
to counteract its injurious effects ; but it is of no 
avail here ; the arsenic has the start of it, and, 
indeed, would outstrip it, with an equal start. 

From the foregoing in regard to arsenic as an 
application for destroying the pulps of teeth, the 
following conclusions are justly deducible : it is, in 
general, very efficient ; it is a heroic agent ; it should 
in all cases be used with great caution ; in some 
cases it is entirely inadmissible ; a free administration 
of it is liable to be followed by bad consequences; 
and skill and care, rather than counteracting agents, 
are to be relied upon in its application. 

Filling Pulp-Cavities and Canals.— A^i^r the pulp 
of a tooth has been destroyed, whether by an opera- 
tion or by therapeutic treatment, the part at the 
point of its detachment should in most cases, before 
the filling is introduced, be rendered healthy ; if pos- 
sible, a permanent cicatrice should be formed. In 
cases, however, of good constitution and strong recu- 
perative power, Avhere a pulp has been removed by 
an operation, the root may be filled as soon as the 
hemorrhage has ceased ; but such cases rarely occur. 
Generally the part will require treatment ; and the 
character and duration of this will be determined by 
circumstances — as, the vital energy of the system. 



TREATING PULP-CAVITIES. 319 

and the method employed for the pulp's destruction. 
When this has been effected by an operation, the 
wound produced by an excision is restored to sound- 
ness much more readily than when by an application 
of arsenious acid, and less topical treatment will ordi- 
narily be required ; indeed, in many such cases there 
will be nothing else required than to keep the canal 
well cleansed, so as to obviate any irritation that 
otherwise might be induced by decomposition. When 
the pulp has been destroyed by arsenious acid, more 
energetic treatment is usually demanded; for then 
there is always a greater or less disposition to slough 
or discharge through the tooth, which must of course 
be entirely abated before the operation of filling is at 
all admissible. In the treatment of this condition, 
the canal should be kept perfectly clean by frequent 
syringing ; floss silk, moistened with creosote and 
tannin, should be introduced to the extreme part of the 
cavity or canal, and should be changed every twenty- 
four hours, the cavity being thoroughly washed each 
time. It will be necessary in many cases to continue 
this treatment for several days. In order to deter- 
mine whether the condition is such as to admit of 
the filling, the floss silk should be removed after a 
sufficient time is supposed to have elapsed, the cavity 
thoroughly cleansed and dried, and a portion of dry 
floss silk or cotton introduced loosely into the canal. 



320 PULP-CAVITIES. 

Then close up the decayed cavity with adhesive wax, 
gutta-percha, or some other substance that will effect- 
ually exclude the moisture ; let it remain thus from 
twelve to twenty-four hours ; then open the cavity 
and withdraw the silk or cotton, and if this is found 
free from moisture or odor, the tooth is ready to be 
filled. 

The treatment just described will be sufficient for 
all cases in which the pulp has been destroyed by the 
operator. But teeth whose pulps are already dead 
would seem to be less difficult of treatment and 
filling ; yet such is not the case ; indeed, the thera- 
peutic treatment of these is usually more protracted, 
and their diseased condition less easily controlled ; 
and this because of the fact that the decaying pulp 
remaining in the canal becomes very offensive and 
irritating to the living parts adjacent, in which it 
induces a chronic diseased condition, frequently in- 
volving the dentine along the walls of the canal in 
decomposition. 

A classification of these teeth, based on their con- 
ditions, might be somewhat auxiliary to a further 
examination of this subject; and the following will 
probably embrace them all : — 

1st. Those whose pulps are dead, but their attach- 
ment and adjacent parts alive and healthy. 

2d. Those predisposed to disease. 



TREATING PULP-CAVITIES. 321 

3d. Those already diseased, either discharging acrid 
matter through the root, or exhibiting inflammation 
of the periosteum. 

4th. Those having alveolar abscess. 

Sound or slightly decayed teeth are sometimes 
found with dead pulps. This condition may be pro- 
duced in various ways : by blows, or by any force 
that will partially loosen the tooth ; by undue press- 
ure in filling ; by excessive sensitiveness of the den- 
tine, even where the decay is not extensive ; and, 
sometimes, by a filling of the tooth when it is in an 
unfit state for the operation. Ordinarily, in cases in 
which the pulp is dead before its exposure, and there 
is no abscess from the root or periosteum, the pulp- 
chamber may be opened and the remains of the pulp 
removed. The canal should then be cleansed out, 
and floss silk, moistened with creosote, introduced and 
permitted to remain from one to six hours, when it 
should be withdrawn, the pulp cavity and the canal 
again thoroughly cleansed, when, if there is no dis- 
charge of pus through the root, it may be filled. 
The fact that the dead pulp is inclosed in its chamber 
without producing irritation is evidence that there is 
no secretion of pus. Occasionally, where the pulp 
has died from exposure, the living part immediately 
adjacent will present a healthy condition, and there 
will be no discharge ; such cases should be treated in 



322 PULP-CAVITIES. 

the manner just described. In operating on teeth 
already dead, more delicate manipulation is requisite 
to prevent irritation than on those in which the pulp 
is destroyed by the operator. In very many cases 
of dead teeth, where there is not a state of actual 
disease, there is a strong predisposition to it ; and in 
these cases the preparation of a cavity, or the intro- 
ducing and condensing of a filling, may produce in- 
flammation of the periosteum. When such a conditon 
is recognized, several sittings may be required to 
complete the operation. It is not always easy to 
recognize such a predisposition ; yet whenever it is 
suspected, it is well to press the investigation, which 
may be guided by the following rules. Ascertain 
whether the tooth experiences a different sensation or 
any pain under percussion in any direction ; whether 
periostisis has ever existed in that or in a contiguous 
tooth ; whether the parts adjacent to the tooth are in 
a healthy state ; whether there is a general inflamma- 
tory diathesis or an enfeebled condition. These are 
the prominent points in an examination of this kind. 
Where this predisposition exists, it may be coun- 
teracted by general or local treatment, according as 
it depends on general or local causes ; but in every 
case, this treatment should be very carefully con- 
ducted, and it will in some instances have to be 
protracted. In those cases where there is a discharge 



TREATING PULP-CAYITIES. 323 

through the root of the tooth, such treatment should 
be adopted as will most speedily and effectually sup- 
press it ; and if it proceeds from a remaining portion 
of the pulp-tissue near the point of the root, this 
should be removed, and such application made as 
will prevent a recurrence of the discharge, and assist 
the part to recover its health. The discharging sur- 
face may be broken up by cutting it away with an 
instrument, or be destroyed with an escharotic — 
either nitrate of silver, creosote, or chloride of zinc, 
in the use of which, several applications will in 
many cases be necessary. From their action, the 
secreting surface is destroyed, healthy granulations 
spring up, and a healthy condition is established. 

The discharge should be wholly suppressed before 
the tooth is filled, otherwise, alveolar abscess would 
probably occur. In cases where there is periostitis, 
it must be subdued before the tooth will tolerate the 
operation of filling. To attain this end, the treat- 
ment required will be dictated by the nature of 
the causes which operate to induce the disease. 

The periostitis of teeth whose pulps are dead com- 
monly has its origin at the point of the root, from 
irritation induced in the beginning by the dead and 
•decomposing pulp and other matter at that point. In 
many instances the inflammation is not confined to 
the root of the tooth on which it beaan, but it will 



324 PULP-CAVITIES. 

extend to the alveolus, the gums, and the periosteum 
of the neighboring teeth. Whenever the existence 
of this disease is suspected, and yet not very appa- 
rent, as is often the case, the examination should be 
very thorough. In some instances, percussion of the 
tooth at one particular point, and at a certain angle, 
will produce pain; whereas, striking on any other 
part of the tooth, or at any other angle, will cause 
none at all. By an exercise of care and discrimina- 
tion, the exact point of disease, even if confined to 
a small space, may be ascertained. For instance, if 
striking on the labial surface of a central incisor, 
near the point, produces pain in the socket, while on 
any other point it does not, the place of the inflam- 
mation is the anterior portion of the root, at or near 
its point. By such means ihe skillful and discern- 
ing will be enabled to form a tolerably accurate 
opinion as to the extent and location of periostitis in 
all cases ; and this is an important consideration, for 
if inflammation is found confined to a small portion 
of a root, the treatment, if local, should be as near 
that point as possible. 

Inflammation of the periosteum may sometimes be 
induced by the presence of foreign substances forced 
down between the free margin of the gum and the 
neck of the tooth, which have remained there till 
they have become vitiated, so as injuriously to affect 



FILLING PULP-CANALS. 325 

the gums and periosteum. A deposit of salivary cal- 
culus sometimes produces inflammation of the gums 
and periosteum. Teeth otherwise healthy are in 
some instances thus affected, though those which 
have lost their internal vitality are much more liable 
to such disease. 

I*re]paring the Teeth and Roots for Filling. — After 
the tooth has been brought to a healthy condition, 
the decayed cavity is first to be excavated and made 
of proper form, the pulp-chamber to be shaped, and 
then the canals and the roots to be prepared for fill- 
ing. For the preparation of decayed cavities here, 
the directions hitherto given on that subject will be 
quite sufficient. In the formation of the pulp-cham- 
ber, the abrupt projecting portions of dentine should 
be cut down ; and if there is any decomposition of 
this, it should be removed. The pulp-chamber may 
be, w^hen it is excavated, of a general retaining form, 
or there may be retaining-points made within it at 
proper situations. In the preparation of the canal 
in the roots, some operators do nothing more than 
cleanse them thoroughly. Another method is to pass 
fine bur-drills into them as far as practicable, thus 
making the opening of the same size all the w^ay, or 
to scrape out the canal with a fine No. 10 excavator. 
Very fine, delicate instruments are required for 
cleansing out and forming the canals ; and they 



326 



PULP-CAVITIES. 



should be quite elastic and of low temper. A set of 
instruments for forming the canals in the roots of the 
teeth have been devised and made by Dr. C. Palmer. 
These are of such forms and sizes as to be suitable 
for every case. They are represented in Fig. 90. 



Fig. 90. 




Before the introduction of these instruments, the 
method of forming these canals was by the use of a 
three or four-sided broach, tapering to a sharp point, 
and in inclination corresponding as far as possible to 
that of the canal. This instrument is employed to 
enlarge the canal, and give it a regular shape ; a 
variety should be at hand, so that one of the proper 
size and taper can be selected. In cleansing and 
forming the canal, care is necessary to prevent the 
instrument from passing entirely through the point 



FILLING PULP-CANALS. 327 

of the root. Such an accident is not very liable to 
occur with the tapered broach ; but with the minia- 
ture excavator, or barbed wire, it is, especially in the 
teeth of the young, where the foramina through the 
roots are large ; and it is especially liable to happen 
to the incisors, the canines, and the palatine roots of 
the superior molars. But after the complete devel- 
opment of the teeth, there is no excuse for an acci- 
dent of this kind, for then there is an abrupt con- 
traction of the canal near the point of the root, which 
may always be detected by a careful introduction of 
the instrument. 

The decayed and pulp-cavities and the canal all 
being thus prepared, are now ready to receive the 
filling. For filling the root, there are several 
methods, one of which is, to prepare small strips of 
gold, of two or four thicknesses of foil; take these 
on the point of an instrument, and pack them into 
the root, in successive folds, till the canal is full. 
Another method is, to take small portions of gold, 
and pack them in, one on another, till the canal is 
full. Another is, to take strips of from two to four 
thicknesses, and from one to two lines wide, and roll 
them on a fine broach in such a manner as to make 
a cone-shaped block, a little longer than the depth 
of the canal to be filled, and of the same taper; quite 
a number of these blocks will be required for any 



328 PULP-CAVITIES. 

given case, of various sizes, lengths, and densities. 
The longest, largest, and least dense should be first 
used, the last requiring to be of less size and greater 
density. These cones may be made as dense as 
desirable by rolling them firmly between the thuijib 
and fingers, after having taken them off the broach. 
They are then introduced with the plugging pliers, 
and passed up as near to the point of the root as is 
consistent with safety. In some instances there 
is danger of thrusting them through the point; 
and in order to prevent this, the end of the first 
block introduced may be made so large that it will 
not pass through, even when forced up ; or, what is 
probably better, a very small round pellet of gold 
may be forced up the canal, as near to the point of 
the root as admissible, and this serves as a founda- 
tion for the subsequent portions of gold, and prevents 
them from passing too far up. The cone-shaped 
blocks may be introduced and consolidated wdth an 
instrument of the same general form as the canal, 
but much smaller. This kind of instrument should 
be made of untempered steel, though some operators 
make them of whalebone, to prevent breaking off in 
the canal, — an unnecessary precaution, since no skill- 
ful operator would ever break off a low-tempered, 
well-polished, properly-formed steelinstrument of this 
kind. After a block is placed in the cavity, the 



FILLIXG PULP-CAXALS. 



329 



instrument is thrust in by its side, consolidating 
the g'old to the side of the cavity. Thus the blocks 
are successively introduced and consolidated, till the 
canal is filled. It is better so to arrange as to intro- 
duce the last portion of the gold near the centre of 
the canaL rather than at the side. The last blocks 
introduced should be stiff and dense, that they may 
be thrust in with considerable force. The method of 
filling canals at present employed by many, is in 
the use of the filling instruments invented by Dr. C. 
Palmer, represented in Fig. 91. There is a variety 

Fis. 91. 




in size and somewhat in form, so that in all positions 
they will readily enter the canals and effectually 
consolidate the gold, which is introduced in small 
cone-shaped pellets, loosely rolled, so that they may 
be thoroughly condensed. 

Another method of preparing gold for filling roots. 



I 



330 PULP-CAVITIES. 



is to take the pure metal, and roll it down on a 
good rolling-mill as thin as possible, keeping it well 
annealed ; of this form the cones, and introduce 
them as already directed. Made in this way, they 
are stiiFer, and fill up much more rapidly than when 
made of foil. They are to be condensed in the same 
manner. Where the canal has been formed with a 
tapered broach, it may be filled w^ith a gold wire, 
made of the same size and taper of the broach ; this 
wire may be cut off at the orifice of the canal, or left 
protruding more or less into the decayed cavity, and 
be covered up with the filling. When a lost portion 
of the form of a tooth is to be restored, such project- 
ing wires may be made very valuable as anchorages. 
Some other substances have been thought quite as 
suitable for filling the roots of teeth as gold. Lead 
has been employed for this purpose ; but the principal 
difficulty with this is, to get it into such a condition 
as to be used with facility; but, if as completely 
introduced, it would probably answer the purpose 
quite as well as gold. Dr. F. Peabody, about three 
years ago, described a method of filling the roots of 
teeth w^ith lead, w^hich his experience, as well as that 
of some others, seems to indicate, in many cases 
at least is very good. It consists simply in forming 
the canal in the root, slightly tapering from the pulp- 
chamber to its termination ; then form from a lead 



FILLING PULP-CANALS. 331 

rod a cylinder or cone of the same size and taper as 
the canal in the root ; let this be driven firmly to its 
place in the root ; the rod may now be cut off, leaving 
a slight projection from the entrance to the canal ; by 
this the orifice can be very perfectly closed ; then the 
pulp-chamber and cavity af decay may be filled in the 
usual manner. Tin foil is also used, and, under 
favorable circumstances, with success. Gutta-percha, 
dissolved in chloroform, is used to some extent, and, 
it is claimed, with decidedly good results. It is pre- 
pared of such consistence as ta be readily pumped 
into even the smallest canals by a little piston made 
by wrapping cotton upon a fine broach; and, after 
having the canal prepared, it is filled by forcing the 
gutta-percha solution in with the appliance referred 
to. Some experiments, too, have been made with 
plaster of Paris and similar substances, for filling 
roots and pulp-cavities, but with rather uncertain suc- 
cess — some claiming instances of success, and others 
reporting, in every instance, failure ; so that there are 
not sufficient data to warrant the adoption of plaster 
or any similar substance in practice. 

In cases in which there is liability to irritation, 
the operation of filling a root is quite enough for one 
sitting ; and in any case, not more than three roots 
should be filled at one time. The filling of a large 
pulp-cavity will occupy one sitting, and that of the 



332 PULP-CAVITIES. 

decayed cavity anotlier. When a respite is thus had 
between the filling of the pulp-cavity and that of the 
decayed cavity, the former should be filled with 
Hill's stopping or gutta-percha, so that no moisture 
may penetrate it ; and then when the latter part of 
the filling is to be introduced, it will proceed as 
though there had been no interruption. From one to 
four days should intervene between the different 
divisions of the operation. The filling of the decayed 
cavity is to be performed according to the directions 
already given. When inflammation ensues after an 
operation of this kind, recourse is had to the treat- 
ment already described for preventing, counteracting, 
or reducing inflammation. 

Some experiments have been made to test the 
effect of restoring the parts to health, forming a cica- 
trice at the point of the root, cleansing this out, filling 
the pulp-cavity and the cavity of decay, and leaving 
the canal unfilled ; and it is maintained that this 
method will, in favorable cases, answer the purpose 
quite as well as that of filling the root, and incur less 
risk. The treatment will be such as already de- 
scribed for the restoration of diseased roots ; all dis- 
charge through it must be suppressed, and all foreign 
substances liable to decomposition removed from the 
canal, so that there may be a complete restoration 
before it is closed. 



FILLING PULP-CAXALS. 333 

Oftentimes, when a tooth has been filled without 
filling the roots and pulp-chamber, if the pulp be 
dead, or if the pulp afterward dies, the chamber 
becomes the receptacle of a very vitiated and acrid 
material, the retention of which will almost invariably 
produce irritation. In all such cases, an opening 
should be made for the escape of the offensive matter. 
This is done, if the filling is not to be removed, by 
passing a small drill into the pulp-chamber or canal, 
just above the filling, as close as possible. The handle 
of the drill should be depressed, so as to give the 
opening a downward inclination from within outward, 
and thus favor the escape of any secretion. 

In the superior molars, this opening may be made 
through the masticatory surface ; it may sometimes 
be in the depressions on the crown surface, even 
though there be no filling. In incisors, it is made 
through the palatine portion of the crown. It is 
better, however, in all cases, to make an opening of 
this kind through the neck of the tooth, just under 
the free margin of the gum, since here foreign sub- 
stances are not so liable to be crowded into it as 
where it is through the masticatory surface. In 
cases in which it is obvious at the time of filling the 
tooth that such an opening will be required, it is 
better to make it before the filling is introduced, as 
follows : first, prepare the decayed and pulp-cavities 



334 PULP-CAVITIES. 

for filling; then drill through the neck of the tooth 
into the canal, to the extreme part of the pulp- 
chamber ; and finally introduce into this hole, its 
entire depth, a piece of smooth steel wire, such as 
will closely fit, leaving it exposed through the de- 
cayed cavity — and if it is not enough exposed when 
introduced, the tooth-bone may be cut away about it, 
till it is fully exposed, when the decayed and pulp- 
cavities are filled in the usual manner, and condensed 
solidly against the wire. After the filing is finished, 
the wire is withdrawn, leaving a smooth, continuous 
opening for the escape of any secretion that may 
collect within. When the opening into the canal is 
not made till after the tooth is filled, there is liable 
to be a space between it and the filling that will 
receive and retain fetid matter, which may become 
very offensive. This method of treatment is, however, 
always to be deprecated, and should never be em- 
ployed except as a last resort, or in cases where it is 
impossible to command the time and opportunity for 
the proper treatment ; and even then it is better to 
make the opening and entrance into the chamber and 
canal just as though it were to receive immediate 
treatment ; for in a great many instances the oppor- 
tunity for that may soon occur. 



DEXTAL PERIOSTITIS. 335 



DENTAL PERIOSTITIS. 



This affection of the investing membrane of the 
roots of the teeth is of frequent occurrence after the 
death of the pulp, but rarely if ever before. Inflam- 
mation of this tissue, in its manifestation, is modified 
by the anatomical structure of the parts. 

Whether there be two membranes in the alveolar 
sockets, the one lining the walls of these, and the 
other investins: the roots of the teeth, is not a matter 
of importance so far as the nature and treatment of 
this affection is concerned. This condition of the den- 
tal periosteum is induced by such irritating causes as 
would produce inflammation in other tissues. 

The first indication of approaching difficulty in this 
tissue is a sense of slight fullness, which invites con- 
tact, and even pressure from the opposing teeth — 
such pressure affording a rather pleasurable sensation 
and seeming relief. 

This condition is brought about by determination 
of blood to the part, and the surroundings being such 
as to prevent free expansion to the capillaries, and 
other small vessels ramifying this membrane, these 
walls are pressed upon in proportion to the force of 
this determination. 

This effort at expansion will occasion, especially 
in those teeth having very conical roots, quite a per- 



336 DENTAL PERIOSTITIS. 

ceptible elongation, and this more particularly occurs 
when active inflammation supervenes, which is the 
sequence of the state of irritation to which reference 
has just been made. 

After active inflammation has occurred, pressure 
or percussion upon the affected tooth usually causes 
great pain, — to such an extent that sometimes the 
slightest contact even by the tongue is intolerable. 

This condition varies much in degree in different 
cases, dependent largely upon the predisposition and 
susceptibility to exciting causes of irritation and 
inflammation, together with the character of these 
exciting causes, whether concentrated in action to a 
mere point, or more extensive in their sphere of 
operation. 

Oftentimes only a very small portion of the peri- 
osteum of a tooth will be affected ; it may be confined 
to the immediate vicinity of the point of the root, or 
to one side, or to the periosteum near the margin of 
the alveolus and the border of the gum. 

Indeed, so circumscribed is this affection often 
found, that the periosteum on one side of a root will 
pass through all the successive stages of inflamma- 
tion to suppuration and destruction, without that 
upon the opposite side having undergone anything 
more than a slight irritation, if even that. In such 
cases the vitality has sufficient power to hold the 



DENTAL PERIOSTITIS. 337 

disease at bay, and confine it to the immediate point 
of attack. 

When there is a systemic predisposition, the local 
exciting causes will sooner and more vigorously 
attack. Always when the pulp of a tooth is devital- 
ized, the periosteum is more liable to disease, and 
perhaps for several reasons. In almost all cases 
there are irritants at hand that did not exist before ; 
and the periosteum is either enfeebled, and conse- 
quently less resistant, or the demand upon its func- 
tion greater than before, in view of its being the 
medium of connection between the normally vital 
tissue and that which is devitalized, or, at best, its 
life very much impaired ; and when the latter condi- 
tion exists, the nourishment received by the cemen- 
tum and dentine is wholly through the periosteum. 
In these facts doubtless are to be found the cause 
of the greater susceptibility of the dental periosteum 
to disease after than before the death of the pulp. 

The exciting causes of this affection are to be 
found in the acrid debris of the dead and decaying 
pulps of the teeth, passing either in a fluid or gase- 
ous state through the foramen at the point of the 
root, and there coming in contact with the perios- 
teum, and in various deposits, calcareous and others, 
insinuated beneath the margin of the gum, encroach- 
ing upon and irritating the periosteum. 



338 DENTAL PERIOSTITIS. 

It is also sometimes occasioned by an extension of 
disease from some other point. As an illustration of 
this, in susceptible cases, the periosteum of one tooth 
may become affected by the action of some local irri- 
tant, and two or more of its neighbors become affected 
by extension of the inflammation. 

Some medicinal agents act specifically upon the 
dental periosteum, inducing a very painful condition, 
thickening of the tissue, and elongation of the teeth. 

Mercurials present an illustration of this class of 
agents. The precise condition produced in the den- 
tal periosteum in mercurial ptyalism is perhaps not 
clearly comprehended. It is more than simple in- 
flammation. It is not modified or controlled by the 
same remedial treatment. It attacks the periosteum 
of living teeth as readily, and with quite as much 
violence, as of those which are devitalized. Alveolar 
abscess is not a common result of this affection of the 
periosteum. 

Treatment. — The treatment of dental periostitis, in 
its details, will be governed by the attendant condi- 
tions, such as systemic predispositions, the vital force, 
and the local causes, and their peculiarities. 

Systemic treatment should have for its object the 
removal or counteracting of predispositions, and the 
abatement of the determination of blood to the part 
in question, by inviting it to other parts, by their 



DENTAL PERIOSTITIS. 339 

stimulatioii, and by introducing into the system such 
agents as will tend to allay excitement in the 
affected, part, and induce, so far as possible, an equi- 
librium of circulation throughout the system. 

The local treatment must also be wisely and faith- 
fully attended to. The principle applicable to the 
treatment of inflammation in any tissue is that to be 
employed here. It will be remembered, however, 
that there are many medicinal agents which possess 
very desirable properties that are still totally ineflGi- 
cient, because of a want of adaptation. We have, 
however, at our command some very efficient reme- 
dial agents for the treatment of this affection, and the 
list is being constantly enlarged. 

We propose here to consider rather the principles 
involved in the treatment than details for special 
cases. 

The causes producing and influencing the disease 
should always be fully apprehended, immediately 
after which the following points should receive atten- 
tion : First, remove all irritants ; this will embrace 
the removal of the dead pulp, and all the debris from 
its chamber, and from the canal in the root or roots, 
and rendering them perfectly free from all offensive 
material, and keeping them so -, and the removal of 
all deposits that may be upon the teeth, especially 
those that may encroach upon the gum, or the alve- 



340 DENTAL PERIOSTITIS. 

olus and periosteum at or beyond the neck of the 
tooth ; also the removal of all injurious and useless 
teeth and roots in the vicinity. 

Secondly, relieve the congestion of the affected 
part, in some or all of the following ways : either by 
systemic influence, as already suggested, or by coun- 
ter-irritation, producing determination to a neighbor- 
ing part, and thus relieving the affected part, or by 
depletion from the gum immediately opposite the 
seat of the affection. 

Counter-irritation may be effected by scarifying 
the gum, or by the application of some irritating 
agent, such as tincture of capsicum, tincture of 
iodine and cantharides. An excellent preparation of 
the latter, denominated cantharidal collodion, is very 
effective. This preparation when applied to the 
gum acts promptly and efficiently in almost every 
case of acute dental periostitis ; it produces desqua- 
mation upon the surface of the mucous membrane 
where it is applied. 

Counter-irritation may be produced, also, by mak- 
ing a deep incision in the gum opposite the tooth 
affected, and introducing a little flock of floss or 
cotton, saturated with creosote, which is to be kept 
in place till the inflammation of the periosteum is 
allayed, which will be effected in from one to five 
days. The silk or cotton should be changed every 



DE^^TAL PERIOSTITIS. 341 

day till the restoration of the tooth to health is 
effected, when it is to be removed, and the wound 
permitted to heal. Mild stimulating applications to 
the gums in the immediate vicinity, to increase the 
circulation, will in some cases be quite sufficient. 
A vapor bath, or warm water applied to the part, is 
often beneficial ; and in some cases a continued appli- 
cation of cold, by means of ice-water, will arrest in- 
flammation of the periosteum. 

The tincture of aconite-root is a valuable local 
application. It is a powerful sedative and antiphlo- 
gistic remedy. This, with equal parts of tincture of 
opium and chloroform, constitutes a very valuable 
local remedy for periostitis. It may be applied by 
occasionally moistening the gum with it, or by 
placing on the gum, opposite the seat of the affec- 
tion, a small pad of bibulous paper or lint, moistened 
with the preparation, which may remain from three 
to five minutes. This may be repeated as occasion 
may require ; usually, however, from one to three 
applications will be sufficient. 

Depletion with many is a favorite method of treat- 
ment, and is often productive of very good results. 
Two or three methods of accomplishing this are em- 
ployed. Simple scarification of the gum, cutting it 
more or less deeply, will secure sufficient hemor- 
rhage, especially if the gums are quite vascular; 



342 DENTAL PERIOSTITIS. 

when this fails, cupping, or the artificial leech, may 
be employed ; but the natural leech is the most effi- 
cient means of local depletion in this treatment ; and 
every dentist should always have these at command, 
and be familiar with their use. The application of 
a leech, in very many cases, will in a short time 
subdue the most violent attack of acute periostitis. 

In the treatment of this affection, hypodermic 
injections give promise of most desirable results ; for 
this purpose the solution of morphine or tincture of 
opium, from ten to twenty drops,, may be injected, 
with a proper syringe, beneath the mucous mem- 
brane, when the pain will be found to subside in a 
few moments, and the severest symptoms be abated 
in a few hours. 

In all cases of periostitis, the sooner it can be 
brought under proper treatment after the attack, the 
more easily will it be subdued. In cases of longer 
standing, where the affection has assumed a chronic 
form, the membrane more or less thickened and 
indurated, and a persistent soreness of the tooth 
affected, heroic and persevering treatment will be re- 
quired to overcome the difficulty ; in the great major- 
ity of cases, however, the result is the formation of 
alveolar abscess, rather than the condition just re- 
ferred to, a description and treatment of which will 
next receive consideration. 



ALVEOLAR ABSCESS. 343 

ALVEOLAR ABSCESS. 

When inflammation occurs in the periosteum to 
the extent that the structural character of the tissue 
can no longer be maintained, then disintegration be- 
gins in it, and the surrounding tissue also, so far as 
it may be involved. When the condition arrives in 
which the life action ceases, the tissue at once begins 
to undergo solution, and in addition to this, the 
pabulum or nutrient material, brought into the dis- 
eased territory, is for the most part vitiated, its 
nutrient quality destroyed, and it is converted into 
debris, except that from it, under favorable circum- 
stances, coagulated lymph is formed, which consti- 
tutes what has been so generally denominated the 
sac, and by some the pus-secreting sac, and by others 
the pyogenic membrane. 

Now, strictly, it is not any of these, but is simply 
a mass of coagulated lymph, varying in quantity, 
when it exists at all, from a little shred or bleb, that 
is but little more than visible, to a mass as large as 
the tooth to which it is attached. As to its location, 
it varies ; sometimes it is embraced by and fills up 
the space between the roots of the molars, either 
superior or inferior. In some cases it is merely an 
irregular mass attached to the end of the root about 
which the disease is ; in other cases it will cover a 



344 ALVEOLAR ABSCESS. 

large part of the surface of the root or roots involved. 
The accompanying illustration (Fig. 92) represents 

Fig. 92. 




the position of the lymph mass on the roots of differ- 
ent teeth. It will be more or less firmly attached 
according to the extent of the disintegration of the 
periosteum — being less adherent when there is the 
greater destruction of the tissue. A portion will 
sometimes, upon the removal of the tooth, remain in 
the socket, with some attachment, though usually 
but slight, to the walls ; this, however, is not its 
usual place of lodgment and attachment. The density 
of this lymph mass varies in different cases. Some- 
times it is quite dense, firm and resistant ; at other 
times so soft and flabby as hardly to support its own 
weight. Now, that this substance is instrumental 
in, or has anything to do with, secreting or forming 
pus, or the material discharged from an alveolar 
abscess, is not established nor warranted by deduc- 
tion nor by fact. 



ALVEOLAR ABSCESS. 345 

Now, the question occurs, what is the object of 
this product ? It may, in the first place, be regarded 
as an abortive effort for the repair of lost tissue, and, 
in the second place, the encystment of the disease- 
producing agent. Neither of these, however, can be 
accomplished. Repair cannot take place so long as 
the disease-producing agent is present; and the cha- 
racter of the agent or agents, and the anatomical 
structure of the parts, preclude encystment. The 
local agents that occasion alveolar abscess may be in 
form either solid, soft-solid, fluid, vapor or gas. 
Some of these could not be encysted in any anatomi- 
cal structure, and none of them can be in the tooth 
socket. This lymph mass is not only of no service 
in respect to reparation, but is a real obstacle to the 
proper accomplishment of that process. This is fully 
recognized in all the proposed plans of remedy ; its 
removal is always regarded as an important factor in 
the treatment. 

The character of the discharge from alveolar ab- 
scess differs greatly in different cases, and somewhat 
at different periods of the same case. It sometimes 
consists of pure or laudable pus ; this is of a yel- 
lowish-white color, opaque, inodorous, sweetish taste, 
and of a creamy consistence. In the majority of 
cases it varies from this, however, exhibiting less the 
character of pus, with diminution of pus-corpuscles. 



346 ALVEOLAE ABSCESS. 

and an increase of vitiated ichorous fluid, in which 
sometimes pus-corpuscles are not found at all, with 
an acridity so great as to excoriate living tissue 
whenever it comes in contact with it. 

Usually, when pure pus is secreted, coagulated 
lymph will be found most abundant; and, on the 
other hand, when a highly-vitiated, acrid discharge is 
found, there will be almost, if not an entire absence 
of the lymph mass. 

The character of the discharge is modified by the 
systemic condition, by the tissue disintegrated, and 
by the character of the local irritants ; and it can 
only be changed by a modification of the first of 
these, and the removal of the latter. 

The size of the abscess cavity varies in different 
cases ; in some it is quite small, involving a very 
little territory in the immediate vicinity of the point 
of irritation ; in others it becomes enlarged, some- 
times to twice the size of the tooth about which it is. 
This difference arises from the varying severity of 
the disease, and the peculiar susceptibility of the 
parts. 

Usually the cavity has attained its full size before 
the evacuation of the pus ; and if this is benign, 
little or no disintegration takes place afterward ; but 
it may be otherwise if the secretion is acrid. 

In an abscess rapidly formed, there is very con- 



ALVEOLAR ABSCESS. 347 

siderable pressure by the contents upon the walls of 
the cavity while it is closed, and this is always the 
cause of pain, which in many instances is very severe. 
So soon as an opening is effected, and the tension 
relieved, the pain in a great measure ceases. 

There are various directions through which openings 
are made for the escape of the pus. Sometimes the dis- 
charge is through the root, sometimes from between 
the tooth and alveolus, and at other times directly 
through the alveolus and gum. There are occasional 
cases in which the discharge will be at a very con-' 
siderable distance from the point of secretion ; but in 
such cases it always follows some natural avenue 
that affords a facility for its passage, as, for instance, 
along a suture. There are cases recorded where the 
issue from an abscess of the central incisor was near 
the posterior portion of the hard palate, and in these 
the channel of the pus lay along the suture of the 
palate bones. Sometimes the opening from an abscess 
of the first or second molar will be opposite the 
bicuspids on the buccal portion of the gum. Alveolar 
abscess is exceedingly variable in character, according 
to the constitutional peculiarities and susceptibilities 
of the patient, the condition of the parts immediately 
adjacent, and, to some extent, the cause which has 
produced it. In a good constitution, after an abscess 
is formed, it will discharge healthy pus. Occasion- 



348 ALVEOLAE ABSCESS. 

ally, yet very seldom, does nature alone effect a per- 
manent cure. In constitutions of a cachectic diathesis, 
alveolar abscess is liable to constant discharge of an 
unhealthy pus, or purulent acrid matter, and the parts 
about it are usually in a diseased condition. 

The cases in which alveolar abscess is most likely 
to occur are those of a manifest inflammatory dia- 
thesis, or those in v\^hich there is considerable local 
inflammation, from some local exciting cause. In 
the cases of constitutional predisposition, the abscess 
after a time assumes a chronic character, constantly 
secreting and discharging pus, but does not usually 
cause much pain, though the tooth from which it pro- 
ceeds will experience some soreness and an uneasy 
sensation. In the acute forms of it, however, there 
will be intense pain. In some cases an abscess will 
be formed without much irritation of the surrounding 
parts, while in others, irritation and inflammation 
will extend to parts more remote, especially if there 
are active irritating agents at work. 

Treatment. — The treatment of alveolar abscess will 
be governed by the constitution of the patient and 
the condition of the part affected ; a case of recent 
origin will yield much more readily than one of long 
standing. When a case has assumed the chronic 
form, and the surrounding parts have become impli- 
cated in the diseased condition, a restoration to 



TREATMENT OF ALVEOLAR ABSCESS. 349 

health is often very difficult. In the earlier periods 
of the profession, the removal of alveolar abscess 
was thought to be, as a general thing, wholly imprac- 
ticable. But by the treatment now employed, this 
affection is readily eradicated, unless the parts in 
the immediate vicinity are very much involved. In 
some cases the accumulation on the point of the root 
is very large, and absorption has taken place, to 
accommodate it; in such instances, this being de- 
stroyed, the space occupied by it will be filled up 
with a healthy tissue. In young persons, when an 
abscess is formed on the point of a root, especially in 
the single-root teeth of the superior maxilla, the dis- 
charge is frequently through the tooth, in conse- 
quence of the large size of the foramen at the point 
of the root ; and generally, in such cases, the local 
treatment may be made through the canal. Some- 
times the discharge is between the root and the wall 
of the alveolus. More often, however, especially in 
persons after complete development, the discharge is 
through the alveolus and the soft parts to the sur- 
face, by the shortest course. 

When an alveolar abscess is influenced by any 
constitutional derangement, general treatment must 
be resorted to, such as the condition indicates. The 
local treatment always demanded is such as will 
break up and destroy the accumulated lymph mass. 



350 ALVEOLAR ABSCESS. 

This is effected either by surgical or therapeutic 
treatment, and frequently, in chronic cases, by both 
together, but in the great majority of acute cases thera- 
peutic treatment alone will be sufficient. In order to 
break up an abscess by an operation, it must be easy 
of access ; and it is very seldom that an operation of 
this kind can be performed through the root of a 
tooth ; but, fortunately, in almost all those cases 
where the discharge is through the root, therapeutic 
treatment alone will answer the purpose. When the 
point of discharge is on the gum opposite the accumu- 
lation on the root, a sharp-pointed bistoury should be 
used, and the cannl of discharge sufficiently opened 
to admit the free use of the instrument at the seat of 
the disease. Then the lymph mass should be dis- 
sected from the point of the root, and removed as 
completely as possible. After this, if the case is a 
favorable one, nature may be left to accomplish the 
work, in which case the detached material will be 
thrown off, healthy granulations developed, and the 
parts restored to complete health. In other cases, 
however, after an operation, nature unaided will not 
complete the cure; but such therapeutic treatment 
must be resorted to as the circumstances seem to 
require. In some cases the opening through the 
alveolus will require to be enlarged; and this part 
of the operation requires great care. All loose 



TREATMENT OF AEVEOLAR ABSCESS. 351 

particles of bone should be removed from the open- 
ing, since, if permitted to remain, they would produce 
irritation, and tend to increase the difficulty. 

When the therapeutic treatment is applied through 
the root, the canal is to be cleansed of all foreign and 
detached matter, and opened freely through to the 
point ; and if the discharge is very fetid, some disin- 
fectant should be used, than which perhaps nothing 
is better than diluted creosote, since a fetid condition 
keeps up irritation. The cleansing of the root may 
be accl)mplished by injection of chloride of sodium; 
after which the agent to act on the disease at its seat 
is to be introduced. There are a number of agents used 
for this purpose, the chief of which are salicylic acid, 
chloride of zinc, nitrate of silver, and creosote, the first 
two being applied in the solid and the latter two in 
the liquid state — though the nitrate may be employed 
in the solid form. (Use of salicylic acid, see Ap- 
pendix E.) The method of using the chloride of 
zinc is to pass it in small portions up the canal, on a 
piece of silk, with a fine probe, entirely through the 
point of the root, which process should be repeated 
every twenty-four to forty-eight hours, as the case 
may indicate. After this, during two or three days, 
floss silk, moistened with a mild solution of creosote 
and tannin, in alcohol, should be applied daily ; and 
then clean silk or cotton may be worn in the canal, 



352 ALVEOLAR ABSCESS. 

chaDged every day, for three or four days, or till it is 
manifest that there is no longer any discharge, and 
that the parts are in a healthy condition. If nitrate 
of silver, in solution, or creosote, is used, a piece of 
floss silk should be moistened with it, and passed 
through the root in the manner already described. 
The nitrate is more prompt of action than creosote, 
and will accomplish a specific object in a shorter 
time. Either of these solutions may, by the use of 
the syringe, be very effectively thrown through a 
root in the following manner : Fill the orifice* of the 
canal with gutta-percha ; drill through it a hole large 
enough to receive tightly the point of the syringe ; 
and then, charging with the solution, inject it 
through the root ; in cases where there is an open- 
ing through the gum, the injection may be forced 
round through this. The condition of the parts will 
indicate how long this kind of treatment should con- 
tinue. Ordinarily, when the discharge is entirely 
through the gum, the bistoury should be used to 
enlarge the opening ; or in some cases it is preferable 
to use the "sea-tangle" tent; for this purpose form a 
plug of this material, in size to fit closely into the 
fistulous opening, where it should be placed and re- 
main for twenty-four to forty-eight hours. AVhen 
saturated with moisture, the tent expands to more 
than double its size when in the dry state. Care 



TREATMENT OF ALVEOLAR ABSCESS. 353 

should be exercised lest too much irritation should 
be produced by the pressure ; this, however, can be 
easily regulated. In many cases therapeutic treat- 
ment alone will accomplish the object; and when the 
opening is large and direct, the therapeutic agents 
may be introduced through it directly to the seat of 
disease. If nitrate of silver, in solution, or creosote, 
is used, it should be introduced to the point of affec- 
tion on a pledget of cotton or floss silk, as hereto- 
fore directed ; or if, as is preferable, chloride of 
zinc or nitrate of silver in solid, it should be passed 
through the opening into the main cavity. This 
treatment should be kept up till the indications are 
fulfilled. 

In the treatment of abscess of the inferior maxilla, 
much difficulty is often experienced from a want of 
free egress for the secretion. While, in the supe- 
rior teeth, the pus may frequently escape through 
the tooth by gravitation, this force in the inferior jaw 
increases the difficulty. The secretion being made 
at the bottom of the socket, it remains there, and is 
frequently pent up till it finds an outlet through the 
gum, somewhere between the point of the root and 
the neck of the tooth. It is in many instances very 
difficult to get an opening as low down as the point 
of the root, since the buccal attachment to the gum 
is usually quite above that point, particularly in the 



354 ALVEOLAR ABSCESS. 

case of the molars and bicuspids. Very seldom, if 
ever, can the coagulated lymph on the root of an 
inferior tooth be destroyed by treatment applied 
through the canal of the root. Some are accustomed 
to make a vertical incision of the gum, as low as the 
point of the root, and perforate the alveolus, and 
treat through this channel, as already described. 
Owing to the disadvantage above mentioned, much 
more energetic treatment is necessary to attain suc- 
cess with an abscess of the inferior than with that of 
the superior teeth. 

In. the great majority of cases, where one-half 
or more of the periosteum of a root is involved in 
abscess, the indications are generally supposed to 
point to the removal of the tooth. In the lower 
teeth, a very serious difficulty occasionally occurs 
from abscess, namely, an external opening and dis- 
charge ; and in all cases where this condition has 
already been reached, the offending tooth should be 
removed. But when such a result is only antici- 
pated, and is yet contingent, treatment may be em- 
ployed to avert it ; and in order to do this, a deep 
and free incision should be made in the gum, oppo- 
site the affected tooth, and poultices applied within ; 
and where there is external swelling, pressure is 
recommended, as follows : Adjust a piece of thick 
sheet-lead to the part, and make the pressure on this 



TREATMENT OF ALVEOLAR ABSCESS. 355 

by means of a bandage comprising it and passing 
round the head. It is supposed that this application 
counteracts the gravitation of the secretion, pressing 
it upward, and thus inducing it to seek an outlet at 
some more desirable point. 

In many cases the most prompt and efficient treat- 
ment consists in the extraction of the tooth involved 
by the abscess. This should be carefully done, that 
there may be no fracture of the alveolus, and no 
laceration of the gum. After the tooth is removed, 
it should receive the following treatment : Remove 
from the root or roots, with the proper instrument, 
all coagulated lymph, diseased periosteum, and any 
foreign substance that may be present. The cavity 
of decay, if one exists, the pulp-chamber, and canal 
in the root or roots, should all be perfectly cleansed, 
formed, and filled permanently. This will occupy 
from thirty to sixty minutes. This part of the work 
should proceed as rapidly as is consistent with tho- 
roughness. Immediately after the removal of the 
tooth, there should be placed in the socket from 
which it was removed a pledget of cotton moistened 
with some preparation that would be acceptable to 
the part, and that will prevent, so far as may be, the 
coagulation of the blood while the tooth is out of the 
socket. For this purpose the tincture or the infusion 
of calendula (marigold) has been used, and also 



356 ALVEOLAR ABSCESS. 

hamamelis virginica (witch hazel) extract ; both of 
these have been used with apparent good results. 
Some, however, prefer to use nothing of the kind for 
this purpose, but rather permit the blood to coagu- 
late in the socket, and remove just before inserting 
the tooth. 

The tooth having been prepared as above described, 
should now be carefully replaced in its socket ; the 
jaws should then be closed firmly, which will carry 
the tooth to its precise position. Ordinarily, no 
stays or ligatures will be required to hold it in 
position. 

Just previous to the replacement, the pledget of 
cotton will be removed, and any debris that may 
be found, clots of blood, and, indeed, any and every- 
thing that does not properly belong to the part as 
living structure, should be taken away. Usually, 
the tooth will become firmly attached within a few 
days. This mode of treatment is practicable even 
when the fistulous opening has been formed through 
the cheek to the external surface. 

In regard to the treatment of alveolar abscess, 
much yet remains to be learned. With the attain- 
ments thus far made in this direction, no aspiring 
dentist will rest satisfied, though in the hands of a 
few it has made great progress within a very recent 
period. 



TREATMENT OF ALVEOLAR ABSCESS. 357 

In a treatise of this character it is impracticable 
to enter into the details of the pathology of this affec- 
tion, or very minutely into the rationale of its treat- 
ment. A thorough knowledge of these involves a 
wide range of pathological knowledge. 



CHAPTER X. 

PIVOT TEETH. 

Whenever the crowns of the anterior teeth have 
become so much decayed that they cannot by filling 
be rendered useful, they may, under favorable cir- 
cumstances, be supplied by artificial crowns con- 
structed on the roots. For the successful accom- 
plishment of this work, the following conditions are 
important : — 

First. The constitution of the patient should be 
good. 

Second. The mouth should be in a healthy condi- 
tion, and without diseased teeth or roots. 

Third. The teeth should be free from calcareous 
deposits, and from all foreign substances liable to 
induce irritation or inflammation. 

Fourth. The attachment of the teeth should be 
perfect and healthy. 

Fifth. A root having a living, healthy pulp is to 
be preferred to one the pulp of which has been dead 
for some time. 

Sixth. The root above the neck should be sound. 



PIVOT TEETH. 359 

Seventh. The root should occupy a correct posi- 
tion in the arch. Prior constitutional treatment will 
often be required where there are unfavorable con- 
ditions. 

The roots of the six superior anterior teeth are 
better adapted for the reception of artificial crowns 
than those of any other in the mouth. The roots of 
the first bicuspids frequently terminate in two points, 
and are always more or less compressed, so that 
they will not receive a pivot large enough to sustain 
a crown ; besides, these teeth are masticatory, and 
crowns pivoted to them very soon become loose and 
useless. The roots of the inferior incisors are also 
compressed, and thus subject to the same disability. 
Occasionally, however, pivot crowns are attached to 
the roots of the superior bicuspids, and the inferior 
incisors, cuspids, and bicuspids. But in order that 
such an operation shall be of any utility, the con- 
ditions must be favorable, the roots with as little 
lateral compression as possible, in a very sound and 
healthy state, and without any tendency to inflam- 
mation. 

The preparation of the root for the reception of 
an artificial crown is a very simple process. It will, 
however, be somewhat modified by the kind of crown 
used, and the method of attaching it. Ordinarily, 
the first step is to remove the natural crown, or any 



360 



PIVOT TEETH. 



remaining portion of it^ with a fine saw or excising 
forceps. Of this latter instrument there are various 
forms, that in most common use having narrow 
transverse edges, closing squarely together, as repre- 
sented in Fig. 93. With these forceps any broken 

Fiff. 93. 




fragments of the crown can he removed with great 
facility. Many operators, placing their edge on the 
neck of the tooth, are accustomed to excise with 
them the principal part of the crown at a single cut. 
This method, however, is objectionable, since it 
always gives too great a jar to the root, and is liable 
to loosen, and in many instances to fracture it, so as 
to unfit it for the reception of the crown. But in 
every case in which an artificial crown is required, 
the natural crown is very much decayed, and in this 
condition is very readily removed with excising for- 
ceps, nipping it off in fragments, beginning where it 
is weakest and thinnest, and encroaching on it till it 



PIVOT TEETH. 361 

is all cut down — at least as far as the forceps are 
available. Yet care is necessary even in this manner 
of using the forceps, least the root be fractured or 
too much jarred. 

After such excision vrith the forceps, the root is to 
be dressed down for the reception of the crown, with 
a round or, better, an elliptical file. But for this 
operation of removing a crown, a very fine, smooth, 
narrow saw, set in a frame (Fig. 94), is in some 

Fig. 94. 




respects preferable to the forceps, it being less liable 
to injure the root than the latter. With this the 
crown is sawed off at the margin of the gum, leaving 
the end of the root about the form required for the 
reception of the artificial crown. In the process, the 
crown being sustained by the fingers, the saw, kept 
constanly w^et, is applied to the tooth, and passed 
along its proximal side to the margin of the gum, 
and then along this through it, cutting it off at right 
angles with its axis. After the crown has been thus 
cut off, the root is fitted Avith a fine, round file, 
for the artificial crown ; and, ordinarily, it should be 
dressed at right angles with its axis. 

At this stage of the work, if the pulp remains 
alive, it should be removed ; and the preferable 



362 PIVOT TEETH. 

method is by direct operation, in the manner already 
described (pp. 307-8). It is better in all such cases 
to avoid the use of arsenic for destruction of the 
pulp : it will often be necessary to destroy it before 
the crown is removed. For a successful operation, 
it is always preferable that the root have the pulp 
living. After it is removed, the canal is to be 
enlarged to a suitable size, with the appropriate 
drill. If there is any remaining sensitiveness of the 
dentine, as is very seldom the case, the bur drill may 
be used for this purpose ; but if not, then the com- 
mon spear-pointed drill will be best. Where, how- 
ever, the canal takes the form of a mere fissure, 
either the bur drill or the four-sided broach may be 
employed. The depth to which the canal should be 
enlarged will be determined by the length of the 
root, but it should in all cases be sufficient firmly 
to retain a pivot, which is from one to two lines ; 
and the diameter of the. hole will be determined by 
the size of the root. The drills should be frequently 
moistened with water, to prevent their clogging. 
The shaft of the instrument in the operation should 
be in a line with the cutting edges of the two adjoin- 
ing teeth, and midway between them, and the drill 
itself should follow the natural canal as nearly as 
possible. 



FITTING THE CROWN. 363 

FITTING THE CROWN. 

The tooth selected should be of a size, shape, and 
color to correspond with the natural crown which it 
is to represent. It should not be ground on the 
sides or point, and, according to general opinion, 
ou2:ht not to be touched with the emerv-wheel at all. 
A dilFerent opinion, however, is entertained by Dr. 
C. Palmer. He suggests the grinding of the entire 
anterior surface of the artificial crown, thus removing 
the vitrified surface of the enamel, by which it is 
claimed that the appearance corresponds much better 
with that of the natural teeth, which, in many cases, 
at least, is correct. The diameter of the neck of the 
crown should correspond with that of the articulating 
surface of the root to which it is to be attached. In 
fitting the crown to the root, the joint should be 
made as nearly perfect as possible, for the tooth is 
thus more permanent and comfortable ; an open joint 
offers a receptacle for the lodgment of food and other 
foreign substances, where they become vitiated, and 
produce unpleasant if not injurious effects. The 
crown may be principally fitted to the root without a 
pivot, by dressing the latter with a round or elliptical 
file, and frequently trying the crown on in its proper 
position. After having been thus pretty accurately 
fitted, a trying pivot of soft wood should be intro- 



364 PIVOT TEETH. 

duced, by means of which, grinding it to its exact 
position, the crown may be fitted to the root in its 
proper position. 

For fitting pivot teeth, Dr. E. Townsend invented 
a round file, with a counterpart, into which the file 
exactly fits ; with the former of these the root is 
dressed, and with the latter the articulating surface 
of the crown. This apparatus would be good were it 
not for the great difficulty of dressing porcelain teeth 
with a file. By care, a very complete fit can be 
made with a round file alone. Some coloring mate- 
rial, as rose pink, for instance, may be put on the 
base of the crown, and then the tooth, with the pivot 
inserted, set in its place, when the root will be 
marked where the crown has touched it, and this can 
be dressed at the point of contact. This operation is 
repeated till a perfect fit is obtained. This method 
is to be recommended to those who have had but 
little experience in adjusting pivot teeth. 

Another method of making the articulation, is to 
dress the end of the root square, and then counter- 
sink it about half a line deep with a square-ended 
bur, about three-fourths the diameter of the root. 
The base of the crown is then ground down, by the 
measure of the bur, perfectly round, so as exactly to 
fit into the depression in the root. The bur used for 
counter-sinking the root should have a centre-point to 



ATTACHMENT OF THE CROWN. 365 

fit into the hole in the root, and thus guide the instru- 
ment. This method of fitting on c^o^Yns is objection- 
able, by reason of its too great exposure of the root 
of the tooth. Fig. 95 represents the bur used for 

Fio;. 95. 



this purpose. It is a method now very seldom em- 
ployed. 

Still another method of making an articulation is, 
to dress up the root as first described ; then take an 
impression of the part in plaster of Paris, and from 
this get a model to which to fit the crown. This 
method, however, is advisable only in cases where it 
is desirable to avoid annoyance to the patient by a 
tedious fitting process. 

ATTACHMENT OF THE CROWN. 

The means of attachment in most common use is 
that of wood pivots ; for these, wood in the natural 
condition is ordinarily employed, though it is much 
improved by compression. The kind best adapted 
for pivots is the fine-grain, tough, slow-growth hick- 
ory, of straight, uniform fibre, which should be 
thoroughly seasoned. For its preparation, take 



366 PIVOT TEETH. 

blocks, six or eight inches long, and split them into 
rods about one fourth of an inch square ; then, with 
a knife and file, dress them down to a size one-third 
greater than that of the intended pivots; afterward, 
pass them through three or four holes of the ordinary 
drawplate inverted, thus making them of uniform 
thickness throughout ; and finally, turning the draw- 
plate, pass them through it in the same manner as 
wire, continuing till the rods are of proper size, and 
all the pores of the wood are closed by compression. 
They should be slightly oiled before being drawn 
through the plate. They may be drawn so as just 
to fit the holes of the artificial crowns, being, of 
course, of different sizes. Pivots thus compressed are 
stiflfer, stronger, and far more durable ; and, there 
being greater density of fibre, there is less absorption 
of moisture, less expansion, and less liability to 
decay, than in wood in the natural condition. 

In arranging the crown in position, care is neces- 
sary to prevent it from being struck by the teeth of 
the opposing jaw, — especially since it often happens, 
where the natural crown has been absent for some 
time, that the corresponding tooth of the lower jaw 
becomes somewhat elongated, and strikes forcibly 
against a properly-adjusted pivot tooth. Such a 
difficulty is met either by filing off the elongated 
tooth, or by grinding out the palatal portion of the 



ATTACHMENT OF THE CROWN. 367 

artificial crown sufficiently to accommodate the elon- 
gation. The former is the better method, and should 
always be adopted when inflammation of the dentine, 
exposure of the pulp, or an irascible condition of the 
surrounding parts do not forbid it : though in many 
instances both methods may be advantageously em- 
ployed. But, by some means the antagonizing 
teeth should always be prevented from coming in 
contact with the artificial crown ; and this latter 
should never press against the tooth on either side 
of it; — indeed, it is better that there be a small 
interval on each side. 

When the crown is in its proper position, the hole 
in the root and that in the crown do not always have 
precisely the same direction ; in which case, a pivot 
will be required, having a curvature according to the 
variation ; and the extent and direction of such in- 
flection should be carefully observed while adjusting 
the crown with the trying pivot. The pivot is to be 
neatly and accurately fitted into the crown first, and 
then the length of it required for the root ascertained 

Tier. 96. 



with the gauge represented in Fig. 9G. This gauge 
consists of a wire of a size freely to enter the pivot- 



368 PIVOT TEETH. 

hole, having a little slide with a flange attached. 
By introducing this wire into the pivot-hole, the slide 
is pressed back, and the depth of the hole indicated 
at once. The pivot is then cut off accordingly and 
dressed to the proper size and inclination, and gently 
pressed to its place with the thumb and fingers. 
Before being introduced, however, it may be wrapped 
with gold foil which wdll serve to protect the dentine 
of the root from decay, and also to preserve the pivot. 
Two or three thicknesses of No. 6 gold foil may be 
placed between the crown and the root, so as to make 
a more perfect joint and exclude the moisture. There 
is, however, not much advantage in an arrangement 
of this kind. A thin sheet of Hill's stopping, placed 
in the joint, makes a better adaptation than the gold, 
and OS artificial may be used for the same purpose, 
and in many instances is far better than either Hill's 
stopping or gold ; the canal in the root above the 
pivot should be filled with gold, though in cases 
where there is a discharge through the root, this 
would not be admissible. 

The canal at the orifice is sometimes considerably 
enlarged by decay, so that when the crown is fitted 
and the canal sufficiently opened for the reception of 
the pivot, there will be a cone-shaped space which 
the ordinary pivot will not fill. There are several 
methods of obviating this difficulty ; one of these is, 



ATTACHMENT OF THE CROWN. 369 

completely to fill the enlargement with gold, and 
then perforate this filling with the proper-sized drill 
for the reception of the pivot ; or, which is better, to 
introduce into the canal a polished steel wire of the 
size of the intended pivot ; round this consolidate a 
filling of gold, having first made retaining points at 
the proper places in the dentine ; finish perfectly 
flush with the end of the root ; and then withdraw 
the wire from the canal, and it is ready to receive the 
pivot with the crown attached. Some operators form 
the wood pivot of such a shape as to fit into and fill 
the enlarged cavity. Another method is, after the 
pivot is fastened into the crown, to build round it, on 
the base of this, a portion of Hill's stopping, of about 
the size and form of the enlargement in the canal ; 
and then the tooth being ready to insert, soften the 
stopping by heat, and introduce it carefully into 
place. The os artificial in such cases is still better. 

It frequently happens, in cases where the pulp 
has been dead for a considerable time, that there is 
more or less discharge through the canal of the root, 
and a tooth is required immediately, or at least 
before there is time for treatment, to abate the dis- 
charge. To such a condition some arrangement 
must be adapted so as not entirely to close up the 
canal, and preclude the escape of pus. For this pur- 
pose a groove may be cut down the wall of the canal, 



370 PIVOT TEETH. 

or, perhaps better, on the side of the pivot through- 
out its length, for the discharge of the secretion. 
Where there is irritation or liability to inflammation, 
a temporary pivot of soft wood, or of hard wood 
loosely fitted, should be worn ; for thus the root is 
less jarred by percussion on the crown, and, if need 
be, the crown and pivot can be removed. 

METALLIC PIVOTS. 

The liability of a pivot of wood to wear off at the 
point between the crown and the root, as well as to 
become offensive, and the difficulty of removing the 
tooth, have led dentists to seek some less objection- 
able material ; and metals have been experimented 
upon, and found in some respects preferable. Gold 
has been employed for this purpose more than any 
other metal. Pivots made of this do not become 
offensive, do not wear off, and admit of any desired 
curve, and of an easy removal of the crown. There 
are several methods of attaching this kind of pivot 
to a tooth, and a very common one is, to fit into the 
hole in the crown a piece of pivot w^ood ; cut it off 
even with the base of the crown, and perforate it 
with the proper-sized drill for the reception of the 
metal pivot, which may be roughened or barbed on 
its sides, and then forced into the place prepared for 



METALLIC PIVOTS. 371 

•it. Another method is to drill into a block of wood ; 
insert the pivot, prepared as above, then dress down 
the wood round it till this will fit closely into the 
crown ; and after it is pressed in, cut off the pro- 
truding portion of wood. In either of these methods, 
when the wood becomes moist, the metal pivot will 
be very firmly retained. This pivot may also be 
attached to the crown by soldering. Place the edge 
of the tooth in plaster of Paris ; set the pivot in its 
proper position in it ; fill this round with fragments 
of gold plate, and put on solder and borax ; heat up 
with a blow-pipe, and draw the solder to the bottom 
of the cavity. Another method, sufficient for all 
practical purposes, is to set the pivot in place, and 
pack round it a stiff- amalgam of jold and mercury; 
evaporate the mercury by heat. A better method 
than any of these is to have teeth manufactured with 
a platinum tube inserted, into which the pivot can be 
soldered. Pivots may also be attached to the ordi- 
nary plate teeth. 

For attaching the metal pivot to the root, it is 
sometimes fitted tightly to the canal, and introduced 
into it without any other substance. This is objec- 
tionable on account of the wearing of the root, certain 
to take place if there is the least jarring or moving 
of the crown. To obviate this, various methods have 
been devised, one of which is to wind floss silk about 



372 PIVOT TEETH. 

the pivot before introducing it ; but this soon becomes 
offensive, and requires frequent renewal. Another 
method is to introduce a piece of wood into the root, 
and drill through it for the reception of the pivot, 
w^hich is squared and roughened, — squared to pre- 
vent it from turning round, and roughened to secure 
it from drawing out. But if it is desirable to re- 
move the tooth occasionally, the pivot should not be 
barbed. 

Metal tubes may be introduced into the roots for 
the reception of the pivots. These tubes are made of 
hollow gold wire of proper size, the method of pre- 
paring which is, to take a piece of No. 30 gold plate, 
from four to six inches long, and from a third to a 
half inch wide, and bend it round a piece of smooth 
polished steel wire of the size of the intended pivot; 
draw both together through a drawplate, down to one 
size larger than the hole in the root ; then take out 
the wire, and solder up the tube ; on it cut a fine 
thread with a screw-plate ; from it cut off from a half 
to three-fourths of an inch in length, and insert into 
this a piece of the wire it was drawn upon ; grasping 
this section with a small vice or pair of nippers, screw 
it carefully into the root ; and having introduced it 
far enough, withdraw the piece of wire, cut off the 
protruding piece of tube with a fine saw, and file and 
neatly polish. The root is thus ready for the recep- 



METALLIC PIVOTS. 373 

tion of the crown, the pivot of which should fit very 
accurately into the tube. A very slight curvature of 
the pivot will enable it to retain a very tirm hold in 
the tube. The tube's inner end may be soldered up 
if desirable ; and if there is decay at the orifice of 
the canal, a flange may be soldered on to its outer 
end, flush with the end of the root, and the decayed 
cavity filled beneath it, the flange serving to retain 
the filling perfectly in place. These tubes can be 
best fitted in with the screw, though they are some- 
times placed in without this, and gold foil packed 
about them to retain them. They may be made to 
receive a square pivot, by being drawn, in their 
manufacture, on a square wire instead of a round 
one. For the escape of pus, as already referred to, 
the pivot may be made of hollow wire, with a hole 
through the crown of the tooth. 

A plate tooth, with a metallic pivot attached, may 
be used instead of the ordinary pivot tooth ; and it 
is in some cases required, on account of the manner 
in which the teeth antagonize. But in all cases 
where a plate tooth is used, it should have a metallic 
base to rest on, and cover the end of the root. Pro- 
perly to construct this, an impression must be ob- 
tained, and models and counter-models made, and 
the base swaged; and then to this the pivot and 
tooth are attached. Irregularity of the teeth, and 



374 PIVOT TEETH. 

especially of the root on which the crown is to rest, 
may require a peculiar adjustment of the pivot, 
which may be very happily effected by the method 
just referred to. 

Occasionally, bad consequences follow the opera- 
tion of inserting a pivot tooth, the most frequent of 
which is inflammation of the periosteum. Rough 
manipulation is very liable to induce this condition, 
where there is an inflammatory diathesis, in which 
case too great care cannot be recommended ; and 
prior treatment will sometimes be advantageous. 
After periostitis has supervened, either constitutional 
or local treatment, or both, may be employed, — con- 
stitutional, by emetics and saline cathartics, and, 
indeed, any agent that will equalize the circulation 
and counteract the inflammation ; and local, by the 
same means as already prescribed for periostitis else- 
where ; in addition to which, it may sometimes be 
necessary to remove the crown and pivot from the 
root. It is always important to commence the treat- 
ment of such cases at the first indications of the 
disease. 

Sometimes, even with considerable care, a crown 
will be split by the introduction or the expansion of 
the pivot, in which case, of course, another tooth 
must be selected. When a pivot breaks off, and a 
portion adheres in the root, this may be drawn out 



METALLIC PIVOTS. 375 

with plierSj or a pivot-extractor, or, if it does not pro- 
trude enough for this, it may be drilled out. A root 
is sometimes split by the expansion of a tightly- 
fitting pivot, or by a blow on the crown of the tooth; 
and when this happens, it must be removed, since it 
cannot be made longer to retain a tooth. Pivot teeth 
should seldom, if ever, be worn in a mouth in which 
teeth on plate are worn. They are now far less fre- 
quently worn than formerly, because, perhaps, of the 
improved method of inserting teeth on plate. Under 
favorable circumstances, however, they may be worn 
with great comfort and usefulness from five to fifteen 
years. 



CHAPTER XI. 

EXTRACTION OF TEETH. 
GENERAL REMARKS. 

The extraction of teeth is an important operation, 
requiring for its proper performance skill, judgment, 
and experience, as well as an accurate knowledge of 
the parts involved. Success in the operation formerly 
was very uncertain; but now, from an increase of 
knowledge in the art of dental surgery, and from 
great improvements in the instruments employed, the 
operation is generally attended with success. The 
ancients were not strangers to this operation, as is 
evidenced by relics found in ancient tombs, with 
teeth absent, under such circumstances as to warrant 
the conclusion that they were removed by the sur- 
geon. Extracting instruments of very ancient date 
have also been found ; and ancient writers, too, refer 
to the operation as one not much more pleasant then 
than now. The demand for this operation rises not 
from fancy, fashion, or caprice, but from dire neces- 
sity — a necessity, too, of great frequency. Very few 
individuals in this country arrive at a mature age 



EXTRACTION OF TEETH. 377 

without being required to submit to it ; and," in- 
deed, the majority, before middle age, lose in this 
manner from four to ten teeth, and many, all. The 
following are .^ome of the objects for which a resort 
is had to this operation : — 

1. To obtain relief from pain, caused either by 
disease of the pulp, by inflammation of the perios- 
teum, or by any other affection involving the teeth, 
that cannot be readily controlled without their 
removal. 

2. To prevent pain in future. This, of course, has 
reference only to those teeth which are ^ery much 
decayed, or rendered useless by any cause, and which 
are liable at any time to occasion disease in the parts 
about them. 

3. To save sound teeth from the attack and ravage 
of decay. This implies those teeth which, by their 
offensive condition, would prove injurious to healthy 
teeth. 

4. To relieve a diseased condition of the contigu- 
ous parts, such as alveolar abscess, neuralgia excited 
by dental irritation, diseased antrum — and sometimes, 
indeed, remote parts, which are in many instances 
affected by diseased teeth. 

5. To anticipate and obviate irregularity. Of this 
there are many cases, in which all the teeth cannot 
be accommodated with a proper position in the arch. 



378 



EXTRACTION OF TEETH. 



and in which the removal of one or more of them for 
this purpose becomes a necessity, if regularity and 
symmetry are to be secured. 

6. To prepare the mouth for a proper reception of 
artificial teeth on plates ; though plates are some- 
times inserted, with the roots of the teeth remaining, 
which is admissible only when the roots and the parts 
about them are healthy; otherwise they should be 
removed. 

Before anything else is done, every case presented 
should be carefully examined, in order to ascertain 
all the circumstances and conditions that might in 
any way affect the operation. It is important to 
arrive at a correct conclusion in regard to the tooth 
or teeth to be removed ; the number of roots, their 
inclination, and the character of their attachment; 
in what manner, and to what extent, the surrounding 
parts will be affected by their removal ; and the 
probable amount of force necessary for this purpose. 
The operator will in many instances be referred to 
the wrong tooth ; for a sound and healthy one is 
sometimes painful from sympathy, and standing in 
contact with a decayed and painful tooth, makes it 
frequently difficult for the patient to determine in 
which the pain exists ; and sometimes difficult for the 
operator, too, especially where the decay is on a 
proximal portion of the tooth, and not easy of 



GENERAL REMARKS. 6^\) 

approach. lu all such cases, great care should be 
exercised, and a thorough examination made. There 
is often extensive decay on the proximal portion of 
the tooth, that is not apparent at first view. 

The constitution is also to he noted — its peculiar- 
ities, tendencies, and susceptibilities : as these ^vill 
often modify the operation. A highly nervous tem- 
perament will not endure an operation that one of 
a different character will undergo with impunity. 
There may also be idiosyncrasies and conditions that 
will forbid the extraction of a tooth. One of these, 
and not the least formidable, is a hemorrhagic dia- 
thesis. 

The manner of performing the operation is an im- 
portant consideration : it should not be precipitate or 
hurried. A verv aood criterion is. that the eve 
should critically follow, and the mind attentively 
comprehend, every movement of the hand and instru- 
ment. It is a very common method to seize the 
tooth, turn away or shut the eyes, and make the most 
rapid motions possible, regardless of consequences. 
Accidents, such as breaking the tooth, fracturing the 
alveolus, laceration of the soft parts, and rupture of 
the blood-vessels, are very liable to follow a hurried 
execution; and there are many cases on record in 
which injury has resulted from a rapid application of 
force in the extraction of teeth. The ancients were 



380 EXTRACTION OF TEETH. 

cautious in this particular : it is recorded of them ; 

that they made extracting instruments of lead, to j 

prevent injury from the employment of too great j 

force. It is difficult, indeed, always to determine • 

what amount of force may be necessary for the j 

removal of a tooth in any given case ; though by long ! 

and close observation, it may be pretty accurately i 

calculated; and it is important for the operator to j 

know it, so as to prepare for the emergency, and to ■ 

select the instrument appropriate to the occasion. ■ 

In order to be successful, an operator must be confi- j 

dent of his ability, and to be so, he must be possessed j 

of it. He should be familiar with the anatomical ' 

structure of the parts to be operated upon ; should \ 

understand the physiological and pathological con- ' 

ditions of the parts adjacent; and should properly \ 

appreciate their influence on, and their connection '■ 

with, the teeth. ; 

There is a great difference in teeth with regard to ; 

their facility of removal. Those most difficult to 

.... j 

extract possess the following peculiarities : shortness ] 

and thickness of crown ; in the incisors, thickness — | 
the edges of the superior and the inferior meeting 
squarely on, or deviating but little from their points ; 
freedom from prominences on the crowns of the mo- 
lars and bicuspids, their masticating surfaces being ' 
smooth ; regularity in arrangement, all being in cor- ' 



GENERAL REMARKS. 381 

rect position and in contact with one another ; color 
slightly yellow ; denseness and thickness of alveolus ; 
unyielding firmness of the soft tissues ; lack of promi- 
nences on the gums to indicate the size and position 
of the roots. Another class of teeth, differing in 
characteristics from those of the above, are also very 
difficult of extraction, namely : those having crowns 
of medium length and of a diameter at the neck much 
less than at the masticating surface ; roots long and 
divergent, and in some cases considerably curved ; 
and often a very firm union with the alveolus, so that 
a portion remains adhering to the tooth when it is 
extracted, which occurs more frequently with the 
superior cuspid teeth than with any others ; and often 
the septum betwen the roots is so firmly embraced 
by them, especially when they converge, that it is 
brought away with the tooth on its extraction. Bony 
union of the teeth has been enumerated as one of the 
occasional obstacles in extraction of the teeth ; but 
this rarely if ever occurs — the mode of development 
almost precluding the possibility of its existence — so 
that it need scarcely be reckoned. Exostosis of the 
root sometimes renders extraction very difficult, 
especially when the enlargement attaches to the point 
of the root, and forms a bulb larger than the diameter 
of the root elsewhere. It is then like a ball in a 
socket, and if the walls of the alveolus are thick and 



382 EXTRACTION OF TEETH. 

firm, and closely embrace the root, the tooth is very 
securely retained. Exostosis of the same extent in 
the inferior as in the exterior teeth will render the 
latter the more difficult to remove, because of the 
greater density of the inferior maxilla ; and it has 
been maintained that this cause would produce a 
like difference even in the normal condition of the 
organs; but experience does not warrant the opinion. 
The superior molars have more numerous and more 
divergent roots than the inferior; and the roots of 
the anterior superior teeth are much larger, and 
consequently have a greater amount of attachment, 
than the anterior inferior ones. In a healthy condi- 
tion, the periosteum of the root has comparatively 
little sensibility ; but in proportion as it is sub- 
jected to acute disease, is the sensibility, and thus 
the pain consequent on the removal of the tooth, 
augmented. 

Instruments adapted to all the different forms and 
locations of the teeth are requisite in the various 
operations of extraction. It is impossible to remove 
all teeth in a proper manner with but three or four 
instruments, as recommended by some. 

For any kind of successful manipulation in the 
mouth, and especially that involved in the extraction 
of teeth, the patient should be placed in such a posi- 
tion as to make him the most comfortable, and to 



IXDICATI0X5 FOR EXTRACTIOX. 383 

secure to the operator the greatest facility of execu- 
tion. But different positions, of course, will be re- 
quired for the removal of different teeth. Finally. 

there should be as little show of preparation, and as 
little display of instruments, as possible. — thus to 
aroid exciting the nervous apprehensions of the 
patient : and the operator should at all times exhibit 
a o-entle and encouradnfr deportment, vet work 
promptly and stirely. 



I>"DICATIO>'S FOR EXIRACTIOX. 

The most common and imperative indication is. 
continued and violent toothache. In all cases where 
the teeth are diseased and painful, and cannot be 
restored to health, they should be removed. There 
are, however, few cases of diseased teeth that cannot 
be relieved by the present methods of treatment, so 
as to remain in the mouth with some degree of com- 
fort and useftd.nes5. Alveolar abscess, terminating 
on the otitside of the face, or tending to it. always 
indicates the removal of the offending tooth. Chronic 
inflammation of the investing membrane used to be 
considered an indication for extraction : but it is 
found that many cases thus affected may by judi- 
cious treatment be restored to comparative health. 
Ulceration of the investing membrane clearly points 



384 EXTKACTION OF TEETH. 



1 



to extraction as the remedy. Teeth that have no 
antagonists, and that, on this account, keep up an 
irritable condition in the contiguous parts, should 
be removed; and so, as a general rule, should super- 
numerary teeth. In order to relieve a crowded 
condition of the teeth, it is sometimes necessary to 
remove one or more, even though they may be 
healthy. 

Till within the last few years, the existence of an 
alveolar abscess was considered an indication for the 
removal of the tooth from which it proceeded, but 
under the present mode of treatment, except in very 
aggravated cases, a simple abscess is not reckoned a 
sufficient cause for extraction. 

The posterior teeth may be removed for causes 
that would not warrant the removal of the anterior. 
All dead teeth and roots that produce or keep up 
irritation should be removed, especially if the ten- 
dency is persistent. 

The temporary teeth that are not cast at or near 
the time their respective permanent teeth should 
appear through the gum, ought to be removed ; but 
caution must always be exercised, lest they be re- 
moved too soon. Painful and uncontrollable disease 
may indicate their removal long before the period 
just mentioned ; yet they should not be removed on 
account of diseased condition unless the rudiments of 



EXTRACTIXa INSTRUMENTS. 385 

the permanent teeth are likely to suffer thereby. 
A crowded condition of the permanent with the tem- 
porary teeth may indicate the removal of one or more 
of the latter. It is important to understand the true 
indications for the removal of temporary teeth ; in 
these, as in the permanent teeth, apparent indications 
are liable to be mistaken for real ones. Teeth may 
sometimes, even though undecayed, produce nervous 
affections, and in such a manner as to render their 
removal necessary. This indication is most frequent 
with teeth affected by exostosis. 

A high state of inflammation in the contiguous 
parts is regarded by some as a counter indication ; 
but it can be such only in cases in which the inflam- 
mation would be increased by the operation ; and this 
would happen only where there is a decided inflam- 
mator}^ diathesis, which peculiarity can be readily 
detected by careful observation. 

EXTRACTING INSTRUMENTS. 

Numerous and various instruments have been em- 
ployed for extracting teeth ; and each of these has 
passed through various modifications. Imperfection 
and want of adaptation have, till within a few years, 
characterized them all in a marked degree, as indi- 
cated by the numerous changes they have undergone. 



386 EXTRACTION OF TEETH. 

Two general classes comprehend them all, repre- 
sented by the key and the forceps. The former 
makes its attachment on one side of the tooth, com- 
ing in contact with but a small portion of it, and has 
a resting point for a fulcrum on the adjacent parts, 
the gum and the alveolus. The latter embraces the 
tooth on both sides, and has no fulcrum resting on 
the adjacent parts. There are other instruments 
somewhat different from these in their application ; 
but the principle on which they operate is the same. 
For instance, the elevator has a point of embrace or 
contact with the teeth, and a fulcrum or resting point 
on the adjacent parts, the power being applied to the 
handle, as to a lever. The screw makes its attach- 
ment inside of the tooth, instead of outside, like the 
forceps, and does not touch any other part. 

There should always be at hand a sufficient num- 
ber and variety of instruments to meet every case, 
however rare its occurrence. Desirabode recom- 
mends the employment of but four instruments for 
the removal of all the teeth. The first is a forceps, 
and the other three are nothing more than so many 
different forms of the elevator. He was not familiar 
with the present improvements in extracting instru- 
ments, or he could not have made such a recom- 
mendation. 



THE KEY. 387 



THE KEY. 



The principle of this instrument was at a very 
early period brought into requisition for the extrac- 
tion of teeth ; it is emphatically an old instrument. 
It consists of a shaft six inches long, with a handle 
four inches, attached at right angles, while the hook 
is attached laterally at the other end of the shaft, 
and the bolster, either movable or fixed, to the side 
of it, immediately below the articulation of the hook. 
This instrument has passed through a great variety 
of forms and modifications ; having the shaft straight, 
curved, or double curved ; the fulcrum large, small, 
flat, round, long, short, fixed, movable, and anterior, 
posterior, or opposite to the point of the hook. There 
has also been a great variety of forms of the hook ; 
and it has been made with machinery attached, to 
control its grasp, the object of which is to prevent 
the instrument from slipping off the tooth, and skill 
in the use of which would doubtless add to the effi- 
ciency of the instrument. The principle of the for- 
ceps, too, has been combined with the key, and pro- 
bably with very decided advantage. 

The rnodus operandi of the key is worthy of some 
consideration. The hook is attached to the shaft 
directly above the bolster, and starts off at a right 
angle with its vertical axis, but curves down to the 



388 EXTRACTION OF TEETH. 

point, almost or quite as low as the base of the bolster. 
When properly constructed, the hook embraces the 
tooth at the neck on one side, and the bolster rests a 
little below this on the other. When the instrument 
is applied to a tooth, the centre of the shaft is the 
axis of motion ; but as force is applied to the instru- 
ment, this axis is transferred from the shaft to the 
base of the bolster, w^hich is the centre of motion the 
moment it is fixed on the gums and alveolus, and the 
shaft describes an arc about it. Now, as a result 
of this motion and arrangement, the line of force is at 
an angle of from forty to sixty degrees with the axis 
of the tooth ; and hence it is at this angle that the 
tooth must be extracted, if at all. The axis of power 
exerted on the tooth by the instrument is in a line 
from the point of the hook to its attachment to the 
shaft ; and the line of this force has its termination 
below the neck of the tooth on one side, and just 
above the crown on the opposite side. The angle 
formed by the line of power with the axis of the 
tooth is different in the diiferent relative positions of 
the key to the tooth. If the instrument is applied to 
an inferior molar, wdth the bolster on the inside, the 
angle of the line of force with the axis of the tooth is 
about forty degrees ; but if placed on the outside of 
the jaw, as recommended by some, the angle con- 
tained by the line of power and the axis of the tooth 



THE KEY. 389 

is sixty degrees or more. The line of force is not 
changed by any form the hook may assume ; — it may 
be regularly or irregularly curved, or be turned at 
right angles, and yet the line of force is not changed. 
Indeed, this line cannot be changed except by 
changing the relative position of the hook and its at- 
tachment. This application of the power constitutes 
one of the prominent objections to the use of the in- 
strument; the force is applied at-too great an angle 
with the axis of the tooth, and hence, in numerous 
instances it is broken off. The bolster of the key 
rests, in the operation, on the gum, on which it 
exerts great pressure, and which it always bruises, 
and frequently lacerates in a cruel manner; the press- 
ure exerted by the bolsters of the variously con- 
structed keys differs but little ; though, perhaps, the 
bolster which has a broad base, and is attached to the 
shaft by a joint, would cause less pain to the patient 
by its pressure, and be much less liable to lacerate 
or cut the gum, than the small and permanent one. 
The pressure of the bolster on the gum and process 
is always greater than the power required to extract 
a tooth; and this extreme pressure and its conse- 
quences constitute another strong objection to the 
use of the key. The power being applied at a disad- 
vantage, much more is required than when economi- 
cally applied. 



L 



390 EXTRACTION OF TEETH. 

This instrument is so seldom employed for the 
extraction of teeth, that any very special directions 
as to its use will scarcely be required ; yet a few gen- 
eral suggestions may not be out of place. Whether 
a tooth should be drawn inward or outward depends 
on its position and inclination. As a general rule for 
the removal of the molars, the bolster should be 
placed on the inside of the inferior teeth and on the 
outside of the superior. For removing the lower 
teeth of the left side, the operator should stand at the 
right of the patient ; and for the teeth of the right 
side, in front or at the right. For the inferior teeth 
of the right side, he should stand at the right of the 
patient; and for the left superior, in front of him. 
There have been a great many different opinions as 
to the manner of applying and using this instrument. 
One recommends that " the teeth should be always 
turned towards the tongue." Another, " that the 
fulcrum should be so placed that it would not come 
in contact with the tooth." Another directs : '' Place 
the fulcrum on the margin of the gum." Another : 
" Place the fulcrum on the gum below its margin." 
Another suggests, ^' that the fulcrum be placed on the 
side of the tooth opposite the point of the hook." 
Again, we are directed that the tooth should be drawn 
from the higher alveolus." This great diversity of 
opinion as to the manner of using the key, as well as 



FORCEPS. 391 

the great variety of changes in its form, is evidence 
that it is, at best, a very imperfect instrument. It is 
impossible to embrace a tooth as deep with it as with 
well-constructed forceps ] and with it, the liability to 
accident in the extraction of teeth is much greater 
than with any other instrument. A strong advocate 
of this instrument says that the key always produces 
injury; but the greatest skill exhibits the least 
injury." 

FORCEPS. 

The forceps are the most efficient extracting instru- 
ments in use, and the improvements made in them 
during the last few years have been very great; 
indeed, twenty years ago they were not made with 
any special adaptation whatever, and were totally 
unfit to be used for the extraction of teeth ; but now 
they are constructed with such various shapes and 
curves, as to facilitate their approach to the teeth, 
whatever their position in the mouth may be, and to 
fit all the various forms, and make the most perfect 
embrace of the teeth possible. Forceps, with the pre- 
sent improvements, take a deeper and more thorough 
hold on the teeth than any other instrument. The 
beaks may be made so thin that they will penetrate 
between the roots and alveolus, and the adaptation so 



392 EXTRACTION OF TEETH. 

complete that the instrument will not slip or move 
from its position when placed. The form of the beaks 
should be such as to fit the crown without pressing on 
it, and yet perfectly embrace the neck of the tooth ; 
and the entire instrument of such form and curve as 
to give to the hand, arm, and body of the operator the 
best position for ease and facility of execution. 

There are various opinions as to the position, rela- 
tive to the patient, which the operator should occupy 
while extracting teeth with the forceps. Some 
recommend different positions for the removal of 
different teeth ; but it is preferable, on many accounts, 
to occupy as nearly as possible the same position in 
the removal of all; and this is to the right and a, 
little back of the patient. 

The forceps for removing the superior incisors are 
straight, and have thin beaks, which are sufficiently 
broad to embrace the anterior and the posterior sur- 
faces of the teeth entire (Fig. 97) ; and they should 

Fig. 97. 




be much broader for the centrals than for the laterals. 
The points should not be so broad, however, as to 



FORCEPS. 393 

come in contact with the contiguous teeth in the 
rotary motion made to break up the attachment. 
The same principle in regard to the width of the for- 
ceps is to be observed for the lateral incisors and 
cuspids. The ordinary straight root forceps may be 
employed for the extraction of the lateral incisors ; 
though, for this purpose, it is desirable that their 
beaks be somewhat thinner than usual. For the 
superior cuspid teeth, the ordinary bicuspid forceps 
are frequently used, but their beaks are commonly 
too narrow, and those of the central incisor forceps 
too thin. The cuspid forceps should be about as 
wide as those for the central incisors, with the thick- 
ness of the bicuspid forceps (Fig. 9S), and with a 

riff. 98. 



greater concavity, so as to fit the neck of the tooth. 
The superior bicuspid forceps have narrow, thick, and 
quite concave beaks, and the instrument is straight, 
or nearly so; though for the second bicuspids, 
especially in a small mouth, it should have some 
anterior curvature. (Fig. 99.) One pair of forceps 
will serve for both sides, thoufrh it is desirable to 



394 



EXTRACTION OF TEETH. 



have one for the fist and another for the second 
liictispid. For the removal of the bicnsjjids, there is 



ri2. 99. 




a form of forceps vrith thick, smootli beaks, and of 
stich a form as. by pressure, to force the tooth from 
its socket, taking advantage for this purpose of the 
conical form of the root. The superior molar for- 
ceps, a pair for each side, have one of the beaks a 
single concave, to embrace the palatine root, and the 
other a double concave, with a projecting point from 
the centre of the beak, to pass into the bifurcation, 
and Tvith the edge of the beak so formed as to em- 
brace the two palatine roots. The concavity and cur- 
vature of the beaks should be just sufficient to accom- 
modate the crown of the tooth. These forceps should 
have a double curve, to facilitate their approach to 
the teeth — an anterior curve just above the joint and 
a downward curve just below it; sometimes, also, 
a lateral curve above the joint, throwing the instru- 
ment more toward the angle of the mouth. (Fig. 
lOO.j 

For the second molars, the forceps should have a 
little more curve above the joint than for the first. 



FORCEPS. 



395 



A third pair of forceps for these teeth, and especially 
for the roots before they are separated, have the 



Fiff. 100. 




inner beak similar to the one above, and the outer a 
curved, attenuated, sharp point, to pass between the 



FiiT. 101. 




buccal roots (Fig. 101). The forceps for the superior 
dens sapientice have two single-concave beaks, made 



I 



396 



EXTRACTION OF TEETH. 



to embrace the tooth, as though it were cylindrical, 
or nearly so, at its neck. The instrument has two 
curves, or rather angles, the one forward and the 
other downward, so that its handle is somewhat 
anterior to, but almost parallel with, the axis of the 
tooth. (Fig. 102.) It is a principle that should be 

Fig. 102. 




observed in all forceps, that the handle of the instru- 
ment when placed upon the tooth be as nearly par- 
allel with the axis of the latter as possible, and as 

Fig. 103. 




nearly in a line with it as the location of the tooth, 
the size of the mouth, and other circumstances will 
admit. 

The forceps for the inferior incisors may have 
either a lateral or a transverse curve, — almost to a 



FORCEPS. 



397 



right angle if transverse, bnt if lateral, not more 
than half that inclination. (Fig. 103.) The ordi- 
nary, slightly curved root forceps may be used for 
the extraction of these teeth. (Fig. 104.) The 

Fig. 104. 




beaks should be very narrow and thin, for a great 
amount of force is not required for the extraction of 
these teeth. The beaks of the inferior incisor for- 



Fiff. 105. 




ceps should be relatively broader than those of the 
forceps for the superior incisors. Rotary motion in 
the extraction of inferior incisors is not admissible 
unless the roots be cylindrical, or nearly so. The in- 
ferior bicuspid forceps are well adapted to the re- 



398 



EXTRACTION OF TEETH. 



moval of the inferior cuspids also. These forceps, two 
in number, one for each side, are of different forms. 
(Fig. 105.) The beaks are narrow, thick, and quite 
concave. The instrument for the right side has a 
lateral curvature, which brings the handle out at the 
angle of the mouth, and is necessary in order to ob- 
viate a contact with the superior teeth. The forceps 
for the left side have beaks of the same form. They 
are bent to almost a right angle above the joint, 
while below it the handle is thrown upward; and their 
inner beak is longer than the outer. The inferior 
molar forceps (Fig. 106) are two in number, that for 

Fio;. 106. 




the right side being curved outward and forward, and 
that for the left forward and upward, the beak mak- 
ing almost a right angle with the body of the instru- 



FORCEPS. 



399 



ment, and the inner beak of each being longer than 
the outer. The beak should be of sufficient breadth 
to embrace the entire side of the tooth, of double- 
concave form, with a ridge and a long point in the 
centre of the beak, to pass into the bifurcation of the 
roots. The inner beak of these forceps should be 
longer than the outer, for the teeth on which they 
are designed to operate have an inward inclination, 
and the outer alveolus is higher than the inner. 

A pair of forceps for the left side, similar in form 
to those for the right, would be preferable to the 
ordinary left forceps, when the mouth can be opened 
wide ; and the curvature of the handle of this instru- 

Fio;. 107. 




ment would be toward the centre of the mouth, in- 
stead of outward, as that of the right forceps. With 
this form of forceps more power can be exerted than 
with the ordinary left inferior forceps. 

A forceps similar in general form to that for the 
extraction of the inferior molars of the right side has 
been devised by Dr. J. A. Watling, for the removal 
of the low^er molars of the left side. 

The instrument has a little more upward and for- 
ward curve above the joint than for the right sidC; to 



400 



EXTRACTION OF TEETH. 



facilitate its approach to and action upon the tooth for 
which it is designed ; it is a little longer than that for 
the right side. This instrument is much more easily 
controlled than the ordinary forceps used for extract- 
ing these teeth, and with it more force can be ap- 
plied. It is far preferable to any forceps hitherto 
used for the extraction of the left inferior molars. It 
is represented by Fig. 108. 

Fig. 108. 




Forceps for the removal of the inferior dens sapi- 
entice have large single-concave beaks, to make a 
general embrace of the tooth, and have but one 
curve, which is between the joint and the point, and 
is almost a right angle. (Fig. 109.) One pair of 
forceps of this kind is quite sufficient for both the 
right and the left side. The forceps denominated 
Phi/ sic s forceps are also sometimes employed for the 
removal of the wisdom-teeth. These are constructed 
with thick, sharp blades, the edges of which come 
squarely together, and the points sometimes have an 
enlargement on them. They are curved almost to a 



FORCEPS. 



401 



right angle, to facilitate their adaptation. (Fig. 109.) 
There are two or three different forms of Physic's 
forceps. 




Of the variety of root forceps now used, those for 
the removal of the anterior teeth are straight, or but 
slightly curved, with long, thin, sharp-edged beaks, 
and of a width regulated by the diameter of the roots. 
Those for the removal of the roots of the superior 
molars, when these are separated, have the same form 
of beaks as those for the front teeth, but more curved, 
to facilitate their approach to the roots. For the 
removal of these roots, it is well to have several pairs 
of forceps with different degrees of curvature, using, 
in any given case, those with the least admissible 
curve, — which in a small mouth will be considerable, 
while in a large one it will be very slight. The same 
forceps that are used for the removal of the front 
inferior teeth are applicable to the removal of their 
roots. 

Of the different forms of forceps for the removal of 
the roots of inferior molars, those for the extraction 
of the roots before they are separated, and while they 
are firmly attached, have two long, slender, round, 



402 



EXTRACTION OF TEETH. 



curved beaks, designed to pass down deep between 
and embrace the roots in the bifurcation ; their curva- 
ture should be almost a right angle, and their handles 

Fig. 110. 




assume the form of the ordinary right and left inferior 
molar forceps, already described (Fig. 110) ; or if 
but one is used, the handle should be straight. The 
forceps for the removal of these roots after they are 
separated should have the beaks of the same form 

Fie:. 111. 




as those of the superior root forceps ; but the beaks 
should be curved to a right angle with the handle, 
and the handle be straight. (Fig. 111.) 



ELEVATORS. 



403 



ELEVATORS. 

There are in use variously-formed instruments 
constructed on the principle of the elevator. They 
are made with such points as to take the most thor- 
ough hold on the teeth or roots on which they are 
to be used, and with such curvature of shaft as to 
enable them to pass most readily to the desired posi- 

Fis. 112. 




tion. Some are so formed at the points as to 
embrace the root at the border of the alveolus, using 

Fig. 113. 




the latter as a fulcrum (Fig. 112) ; others, to pass 
between the alveolus and the root (Fig. 113) ; others, 
to cut through the alveolus, and thus approach the 
root. All the ordinary elevators make a fulcrum of 
the alveolus, or of an adjoining tooth ; but some ope- 
rators, in using this instrument, contrive to make a 
fulcrum of the thumb or one of the fingers, which is 
the preferable way. 



404 



EXTRACTION OF TEETH. 



HOOKS. 



These are formed so that the point will embrace 
the root and remove it, without resting on the sur- 



rounding parts. 



The root is removed simply by 

Tip-. 114. 




pressure, applied in the proper direction. Of the 
various forms of this instrument, there are the for- 
ward hook, the backward (Fig, 114), and the com- 
pound (Fig. 115), which last includes the former two. 

Fig. 115. 




These are valuable instruments, but require care, in 
order to avoid injuring the surrounding parts. 



SCREW. 

This is a cone-shaped instrument, with a very 
definite, sharp screw-thread ; the manner of using 
it in the operation of extraction is, to screw it into 
the root. It will be required of various sizes, to 
correspond with those of the different roots to be 



SCREW. 



40i 



extracted. It is commonly attached to the handle 
by a permanent shaft (Fig. 116) ; but sometimes it is 



Fig. 116. 




made with a square shaft fitted into a socket handle 
(Fig. 117), by which arrangement the handle is used 
only to introduce the screw ; and this serves only as 
a support to a frail root, the forceps being then 



Fig. 117. 




brought to bear in connection with it for the removal 
of the root. A screw-tap of the same form as the 
screw should accompany it. 

When the screw is combined with the forceps for 
the purpose of supporting the root, and preventing it 
from crushing while it is removed with the forceps, 
the latter is of the same form as that of the ordinary 
straight root forceps, with the shaft of the screw 
attached in the joint. In some, the screw is attached 
with a spring and ratchet, so that it can be drawn 
out, seized between the beaks, and introduced into 
the root; and then these are slipped on the root, 
Avhich they embrace and remove. In others, the 



406 EXTRACTION OF TEETH. 

screw is fixed ; but the movable screw is to be pre- 
ferred. (Fig. 118.) An arm attached by a joint, 

Fig. 118. 




and bearing a pad, to rest as a fulcrum on the other 
teeth, is sometimes attached to the shaft of the screw ; 
but this is objectionable, because of its liability to 
impede the action of the instrument, and also to 
injure the adjoining teeth. 

GUM-LANCET. 

Of the various forms of the gum-lancet, the most 
common is that with the round point, and with the 
blade from two to four lines wide, and from half an 
inch to an inch long, attached to a shaft and handle, 
the whole being about six inches in length. The in- 
strument should have a keen edge on the sides, two 
or three lines from the extreme point. It is some- 
times made with the edge square ; but the round 

Fig. 119. 




edge is the better form. The edge is parallel with 
the handle in the ordinary lancet. (Fig. 119.) This 



GUM-LAXCET. 407 

form is used for separating the gum from the buccal 
and palatal surfaces of the tooth. A lancet with the 
edge transverse to the shaft is required for separating 
the gum from the proximal portions of the teeth. 
The blade of this should be of the same general 
form as that already described, except that it should 
be quite narrow — in no case more than two lines 
wide. (Fig. 1-0.) Gum lancets are made with the 

Fig. 120. 




blade set in a socket on the end of the shaft, so that 
it can be rotated and set to any angle to meet every 
case. 

A very ingenious instrument, invented by Dr. 
Merry, and denominated "Merry's Revolving Gum- 
lancet," was devised and constructed about fifteen 
years ago. This is a very excellent instrument — 
superior, indeed, to anything else of the kind, at 
least it was at that time. (Fig. 121.) The following 
is a description of it : " It consists mainly of two 
shafts : one is round and small ; the other is larger, 
part round, and part octagon. Just back of the 
spiral spring which curves down at the lancet end, is 
seen a piece connecting the two shafts. This piece 
is soldered fast to the round shaft, while the upper 



408 EXTRACTION OF TEETH. 

end of it forms a collar in which the round part of 
the larger shaft slides back and forth djidi , revolves. 

Fig. 121. 




On the other end of the large shaft is seen a screw, 
made by winding a wire spirally round it. From the 
small shaft arises another, but shorter, spiral wire, 
which fits into that upon the larger shaft. The short 
one may be considered the nut, in which the other 
revolves. The ends of the short spiral are soldered 
fast to the small shaft. If, then, the large shaft is 
revolved, the screw on it, playing in the nut, is made 
to slide back and forth accordingly as it may be 
revolved. This motion, then, changes the direction 
of the point of the lancet to the plane of the shafts, 
any degree from a right angle to a parallel. Having 
thus got the inclination which is desired, the blade is 
inserted into the gum at the point at which the in- 
cision is to begin ; and as the instrument cuts, rotate 
the larger shaft slightly, and the blade will follow 
the outline of the tooth as it cuts round it." 

THE METHOD OF LANCING THE GUMS 

In all cases the gum should be separated from the 
tooth as far as the embrace of the forceps is to ex- 



METHOD OF LANCING THE GUMS. 409 

tend ; the lancet should pass close to the tooth, so as 
to make the separation clean about its neck ; — in 
order to do which, the lancet must be kept in good 
condition ; it should also be passed freely between 
the teeth. A complete separation of the gum is 
essential to a good hold of the forceps on the tooth. 
Some operators, however, do not use the lancet for 
this purpose, but tear the gum away by forcing the 
forceps to its position on the tooth. This method is 
objectionable on several accounts : it causes the 
patient much more pain than with a sharp lancet; 
the forceps cannot thus be adjusted to the tooth with 
so much facility; there is far more danger of lace- 
rating the soft parts, and because of an imperfect 
adaptation of the forceps to the tooth, more danger 
of fracturing it : and the operation is always more 
difficult of accomplishment. In those cases in which 
the gum is firm and dense, and would obstruct the 
free passage of the forceps to the proper position on 
the tooth, it is sometimes necessary to make a verti- 
cal incision of the gum, even after it has been sepa- 
rated, directly opposite the root. But it is in many 
instances better to cut away a portion of the free 
margin of the gum in the extraction of roots that are 
partially covered by it ; and there is no objection to 
this method in any case where it may at all facilitate 
the operation ; for this portion of the gum, if let 



410 EXTRACTION OF TEETH. 

remain, is always absorbed or sloughed away after the 
extraction of teeth. It is also sometimes necessary 
to dissect the gum somewhat from the alveolus, in 
those cases in which a deep hold on the tooth or root 
is required, and in which the alveolus is either cut 
away or embraced by the forceps. The character and 
condition of the tooth will somewhat modify the 
extent to which the gum lancet should be used. 



EXTRACTION OF THE TEETH. 

In the following remarks it is the design to con- 
sider only those principles obviously involved in the 
extraction of the teeth with forceps, and in the 
extraction of roots with forceps, elevators and screws. 

Superior Incisors. — After an examination, the gum 
should in all cases be perfectly separated from the 
neck of the tooth, up to the border of the alveolus ; 
this is quite sufficient if the tooth is not too much 
decayed. With the forceps already described (see 
Fig. 97), grasp the tooth firmly at the border of the 
alveolus ; introduce the instrument slowly, adjusting 
it carefully as it passes up to the proper position ; 
then, by a gradual movement, rotate the tooth in the 
socket, thus breaking up the attachment. All the 
cylindrical, single-root teeth may be luxated by a 
rotary motion. There are occasional circumstances. 



EXTRACTION OF TEETH. 411 

lioweTer, that render this somewhat difficult — as. for 
instance, any considerable curvature of the root, or, 
sometimes, the attachment to the outer plate of the 
alveolus is so firm, that it cannot be broken up by 
rotary motion. Neither of these difficulties is usual 
with the lateral incisors, but with the centrals, one 
or other of them is not unfrequent. When either of 
them does occur, the attachment must be broken up by 
an inward and outward movement, which, on account 
of the pressure made on the parts, is attended with 
much more pain, and far greater danger to the con- 
tiguous parts, than the loosening by rotary motion. 

The roots of the incisors are not difficult to remove, 
unless, being very much decayed, they will not sus- 
tain the embrace of the forceps below the border of 
the alveolus ; and when they are thus decayed, one 
of the following methods may be adopted : The gum 
may be dissected from the alveolus, and the latter 
cut awav with the thick cuttins: instrument, so as to 
expose the root sufficiently for extraction with the 
root forceps ; or, after the gum is dissected up, the 
alveolus and the root mav be too^ther embraced, 
and the former broken and removed with the latter. 
This is a rough and severe operation, though it is 
often adopted. Or, an elevator of the proper form 
may be introduced between the root and the alveolus, 
and the root thus disloda-ed. 



412 EXTEACTION OF TEETH. 

The screw, either simple or compound, is a valuable 
instrument for the removal of these roots. But the 
gum should be separated even when the extraction 
is to be accomxplished with this. The canal in the 
root should first be enlarged with a taper drill, of the 
same shape as the screw, till all the softened dentine 
is removed. Then the screw, selected of proper 
size, having a very sharp thread, is introduced, till it 
takes a strong hold in the solid dentine, especially if 
it is the simple screw. In some instances, while it is 
being introduced, the root will be loosened. In using 
the screw in connection with the forceps, it is not 
necessary to introduce it with the same firmness as 
when the screw alone is employed. In the use of the 
screw-forceps, the screw is embraced in the beaks, 
and introduced ; then the forceps are passed up on 
the root, or between it and the alveolus, if need be, 
the screw serving to sustain the root under the press- 
ure of the forceps. The attachment of the root is 
broken by a rotary, or an inward and outward move- 
ment, as the case may require. 

Superior Cuspids. — For the removal of these teeth, 
the central incisor or the bicuspid forceps may be 
used, though usually the beaks of the former are too 
thin, and those of the latter too narrow. The forceps 
appropriate for the removal of these teeth have 
broad, deep, concave beaks, so as to embrace the 



EXTRACTION OF TEETH. 413 

tooth as completely as possible ; and they ai^e thick, 
so as to possess sufficient strength. The gum being 
separated, and the forceps adjusted on the tooth, the 
attachment is broken up, either by an inward and 
outward or by a rotary movement ; the former will 
be far more frequently brought into requisition, since 
these teeth are generally so firmly attached that they 
cannot be loosened by the latter ; but the skillful 
and experienced operator will often combine the two, 
with the happiest effect. These teeth have larger 
roots than any others in the mouth, and the alveolar 
process, especially the outer plate, closely invests 
them ; and thus they are very firmly fixed in the 
sockets, and are also more frequently found curved 
than the roots of the incisors. Often, in extraction 
of the cuspids, a portion of the outer wall of the alve- 
olus is broken off, and comes away with the tooth. 
But this accident is not attended with any serious 
results ; indeed, in the preparation of the mouth for 
artificial teeth, it is desirable that it be broken away 
somewhat. 

The movement in the extraction of a tooth should 
always be very deliberate — never sudden and vio- 
lent. A very good criterion in regard to the rapidity 
of movement is, that the eye should follow and dis- 
tinctly recognize every motion of the forceps, the 
tooth, and the contiguous parts. 



414 EXTRACTION OF TEETH. 

The removal of the roots of these teeth is far more 
difficult than that of the incisors. Frequently the 
gum has to be separated up two or three lines on the 
alveolus, and the latter broken in with the forceps, 
before the root is removed. The compound screw is 
often very A^aluable in the removal of these roots, — 
the simple screw not commonly being of much avail, 
since the force necessary to extract the root is gene- 
rally so great that the screw alone will not take a 
sufficiently firm hold to accomplish it. The elevator 
is not a very efficient instrument in the removal of 
these roots. 

Superior Bicuspids. — For the removal of the bicus- 
pid teeth of both sides, one pair of forceps is quite 
sufficient. (See Fig. 99.) These forceps are without 
any curve ; though in a small mouth, for the second 
bicuspids, a slight anterior curve would be desirable, 
since it would admit the instrument to a better posi- 
tion on the tooth. These forceps properly adjusted 
on the tooth, according to the directions already 
given, the attachment is broken up by an inward and 
outward movement, carried just to the extent neces- 
sary to accomplish the object ; and then traction is 
applied to remove the tooth from the socket. This 
application of the force is specially adapted to the 
first bicuspids. Rotary motion should be very seldom 
applied to these teeth, because their points generally 



I 



EXTRACTION OF TEETH. 415 

terminate in a bifurcation, and it is impracticable thus 
to detach them without breaking off at least one of 
the roots ; and where they do not bifurcate, they are 
so much compressed as generally to forbid such a 
force. Occasionally, however, there is but one root, 
and this is nearly cylindrical, as will be indicated by 
the cylindrical form of the crown and neck of the 
tooth; and in such cases the rotary may be combined 
with the inward and outward motion. The root of the 
second bicuspid commonly has no bifurcation, and is 
usually somewhat compressed ; and, in general, the 
rotary motion may be combined w^ith the inward and 
outward in its extraction. There is occasionally, how- 
ever, some curvature to the roots of these teeth ; but 
very seldom is it sufficient to cause any difficulty in 
their removal. The skillful and experienced operator 
will in most cases determine very accurately the 
size, shape, and position of the roots by the peculiar- 
ities of the crown ; and the attention of the young 
practitioner should be directed very closely to this 
point, till he is able to arrive at accurate conclusions. 
For the removal of these teeth, there are forceps with 
thick, peculiarly-formed beaks, constructed to take 
advantage of the conical shape of the roots. The in- 
strument is placed on the tooth at the border of the 
alveolus, or, if need be, a little beyond it ; and then, 
the process having been first cut away, firm compres- 



416 EXTRACTION OF TEETH. 

sion is made on the handle of the instrument, and 
thus great pressure on two sides of the root,— which 
are relatively as two inclined planes, — by which the 
tooth is forced directly from its socket, without either 
the oscillating or the rotary motion. This instrument 
is rarely ever applicable to the removal of any other 
teeth than the second bicuspids, and occasionally the 
central incisors, and then only when the roots are 
very tapering. The roots of the bicuspids, especially 
the second, are usually not difficult to remove. Some- 
times, however, the first bicuspids have two well- 
formed roots, somewhat divergent, that are difficult 
to remove, especially if the decay has eaten away 
till there is little of the tooth left for the instrument 
to take hold upon. But, frequently, if one of the 
contiguous teeth is absent, a lateral seizure will re- 
move the root at once. 

Root forceps with narrow, thin beaks, which may 
be readily forced between the root and the alveolus, 
are very valuable for the extraction of all small 
roots. 

The screw, whether simple or compound, is not 
applicable to the extraction of the roots of the 
bicuspids. 

A bicuspid will sometimes stand somewhat out of 
the true circle, and the contiguous teeth approximate 
so that it will not pass between them. In such a 



EXTRACTION OF TEETH. 417 

case, the principal part of the moTement for its de- 
tachment should be in the direction of its inclination. 
The cuspid teeth are sometimes found in the same 
condition, and a similar application of force for their 
removal is to be made ; indeed, this method is appro- 
priate to all cases Avhere the teeth stand out of a 
proper position, and the contiguous teeth impinge on 
the space. 

Superw Molars. — The first and the second superior 
molars have each three roots, one palatal, and two 
buccal; the palatal being the largest and longest, 
and the anterior buccal larger than the posterior. 
The palatal root diverges very considerably from the 
axis of the tooth, while the buccal are often parallel 
with it and wdth each other ; but they sometimes 
diverge in both directions. Occasionally, the diver- 
gence of some or all of these roots is so great, that 
they cannot pass out of the socket without either 
fracturing the alveolus or breaking off one or more of 
the roots. On the contrary, there is sometimes such 
a convergence of the buccal roots, that the interven- 
ing portion of bone is necessarily brought away with 
the tooth. Indeed, the three roots are sometimes 
found all in contact, forming an irregular conical root ; 
but this is a condition of unnatural development. 

The appropriate forceps being firmly fixed on the 
tooth, an outward and inward movement is applied. 



418 EXTRACTION OF TEETH. 

and traction at the same time. In the examination 
of these teeth, to ascertain the force necessary for 
their removal, two particulars have to be considered : 
the firmness of the attachment, and the position and 
inclination of the roots. When these teeth, as they 
occasionally do, stand somewhat outside of the cor- 
rect position, great care must be exercised in their 
removal, especially if the contiguous teeth impinge. 
In small mouths, the contiguous impinging tooth is 
liable to be injured by the pressure in extraction; but 
this injury may be avoided by directing the pressure 
backward. Commonly, the first effort made to break 
up the attachment should be outward, except where 
the tooth stands inside the circle, or where it is 
decayed very much on its inner side, while its outer 
remains firm. In those cases in which the roots 
diverge so much that they will not pass out of the 
socket without tearing away some of the wall of the 
alveolus, it would be impossible to break up the 
attachment by an inward movement, for the palatal 
root braces the tooth, and the inner process is very 
strong and unyielding. Where a molar has decayed 
on its proximal sides, and the contiguous teeth en- 
croach on it, so that it cannot pass out directly 
between them, it must either be cut away with the 
chisel, file or disk till it is small enough to pass out, 
or be drawn from between them. 



EXTRACTION OF TEETH. 419 

The decay on the buccal or palatal sides often 
extends below the gum, and even below the border of 
the alveolus ; or there may be extensive softening 
of the dentine of the crown ; in either case, the gum 
and process must be cut away sufficiently to admit a 
firm hold on the root where it is strong enough to 
sustain the embrace of the forceps. 

Extraction of Roots.--— The extraction of the roots 
of the superior molars is not attended with much 
difficulty when they are separated by decay, or are 
easily broken apart ; the method then is the same as 
for single roots. They should be deeply embraced 
with the curved, sharp-pointed root forceps (see Fig. 
104), and rotated to break up the attachment, trac- 
tion being applied at the same time. It is very 
rarely necessary to resort either to the elevator or to 
the screw for the removal of these roots. The 
greatest difficulty is experienced when the bifurca- 
tion is deep and the roots all adhere firmly together. 
In such case, the same force is required for their 
removal as before the crown was decayed off. The 
root forceps, shown in Fig. 101, can be very effect- 
ively used in the extraction of these roots. The 
round, sharp beak is passed between the buccal roots, 
the other beak embracing the palatal ; and with this 
hold, by an inward and outward movement, the root 
is removed. These forceps are not applicable where 



420 EXTRACTION OF TEETH. 

there is but one large conical root. For the removal 
of roots of this form, the wisdom-tooth forceps, or 
those with similar beaks, are required. When it is 
necessary to dissect off the gum, and cut away the 
process, in order to obtain a firm hold of the root, this 
should be done in preference to crushing in the pro- 
cess with forceps — except, indeed, it may be the case 
of a very irritable patient, who will not tolerate a pro- 
tracted operation, in which case it is better to com- 
plete the operation at a single effort. 

Third Molars. — There is not usually much difficulty 
attending the extraction of these teeth. The appro- 
priate forceps for this purpose (see Figs. 102 and 107) 
have two large single-concave beaks, so formed as to 
embrace the neck of the tooth, without any reference 
to the bifurcation or the number and position of the 
roots. Ordinarily, the attachment of these teeth is 
broken up by the inward and outward movement; but 
where a single, round, conical root is clearly indicated, 
the rotary movement would be preferable, or the 
rotary in conjunction with the inward and outward. 
These teeth sometimes stand out of the true position, 
more frequently inclining outward, as already sug- 
gested in another place ; and the direction of the 
force for their extraction will correspond with this 
inclination. 

Sometimes these teeth are very difficult to extract ; 



EXTRACTION OF TEETH. 421 

and this difficulty is dependent on the following cir- 
cumstances : first, an anterior inclination of the tooth, 
so that it stands at a considerable angle with the 
adjoining tooth, and in contact with its posterior 
proximal surface, the posterior border of the process 
being thick and firm, and extending down full on 
the crown of the tooth ; and second, the existence of 
several roots, with great divergence, irregularity, and 
curvature. The removal of a tooth in the first of 
these conditions is often a very protracted operation, 
fraught with much pain to the patient and consider- 
able labor to the operator. Such preparation must 
be made as will permit a free egress of the tooth 
from the socket, before an effort is made for its 
extraction. This is effected either by cutting away 
the portion of process behind the tooth, so that it may 
be forced backward sufficiently to let it pass out of 
the socket, or by cutting away enough from the 
anterior portion of the tooth; or, if the posterior 
proximal surface of the second molar is decayed, it 
may be quite as well, and more convenient, to cut 
this down so as to permit the ready removal of the 
tooth. 

Physic's forceps can be used very effectively for 
the extraction of these teeth when they occupy such 
a position, provided the root is straight, or has a pos- 
terior curvature ; but if there is an anterior curvature. 



422 EXTRACTION OF TEETH. 

the tooth is -most difficult to extract, and Physic's 
forceps would be wholly inefficient, except to break 
off the tooth. In such case, the posterior portion of 
the process should be cut away as much as possible. 
Physic's forceps are frequently employed for the 
removal of these teeth when they occupy a correct 
position; but their use is somewhat objectionable, 
especially in the following respects. The instrument 
acts first on the principle of a wedge, being forced 
between the teeth ; and then on that of a lever, the 
second molar being the fulcrum ] and hence, when it 
is employed, the second molar must always be pre- 
sent, and is liable to injury from the pressure, which 
may do violence to the periosteum, or fracture and 
scale off portions of the enamel. But if the first 
molar is absent, there is almost as much liability, with 
the Physic's forceps, of loosening the second as of 
extracting the third. Indeed, it is always objection- 
able to use a sound tooth, under any circumstances, 
as a fulcrum for an extracting instrument. 

A wisdom-tooth the roots of which are irregular in 
number, inclination, and curvature, should be grasped 
firmly, and an oscillating force applied sufficient to 
remove it from its socket. There is nothing per- 
taining to the removal of the roots of these teeth 
that involves any different principle or application of 
instruments from that given for the removal of the 



EXTRACTION OF TEETH. 423 

teeth themselves. The anterior inclination, which so 
often renders the whole tooth difficult of extraction, 
very seldom affects the removal of the roots. These 
are, in general, easily extracted with the common 
curved root-forceps. 

Imferior Incisors. — In the extraction of these teeth, 
either of the forceps described for the purpose may be 
employed. The beaks should be quite narrow and 
thin (see Fig. 103). The instrument well fixed on 
the tooth, the attachment is broken up by an inward 
and outward movement, the rotary being seldom 
applicable, since, in general, the roots are flattened, 
and in many cases quite thin, so as to be incapable of 
turning in the socket. Care must be exercised in 
the oscillating movement, and especially where the 
tooth to be extracted stands out of the proper position, 
and the contiguous teeth incline together; though this 
is of little consequence where the teeth are all to be 
removed. When the crowns of these teeth are short 
and thick, the roots are shorter, thicker, more coni- 
cal, and more nearly cylindrical ; and in the extrac- 
tion of such the rotary may be combined wdth the 
oscillating movement. 

There is seldom any superadded difficulty in the 
removal of the roots of these teeth^ the same instru- 
ments and movements being applicable as for the 
removal of the teeth themselves. The only dif- 



424 EXTRACTION OF TEETH. 

ference in any respect is, that where the teeth are 
decayed off far down, the forceps should be forced 
down on the process, in order to obtain a firm hold on 
the root. Neither the elevator nor the screw is ever 
required for the removal of these roots. 

Inferior Cuspids. — These teeth may be removed 
with the inferior bicuspid forceps of the right side, 
though an instrument of the same general form, 
but of less curvature, would be preferable, since 
with such the required movement for breaking up 
the attachment could be more easily given. They 
commonly have long, round, conical roots, not so 
large as those of the superior cuspids, nor so diffi- 
cult to extract, seldom having any curvature, and 
thus being susceptible of detachment by the rotary 
motion. They often stand so much anterior to the 
true circle, that an attempt to thrust them inward 
would be liable to break or loosen the lateral incisors. 
Their situation, as indeed that of all teeth, should be 
strictly attended to before any attempt is made to 
remove them. 

The crowns of these teeth decay off, and leave the 
roots standing, far more frequently than do those of 
the superior bicuspids. But there is no difficulty in 
the removal of their roots, and the only indication is, 
when they are deeply decayed, to pass the forceps far 
down on them, either first cutting away the process 



EXTRACTION OF TEETH. 425 

or embracing it. as the circumstances may warrant, 
the former method being preferable. After the root 
is extracted, the fractured pieces of process, if any, 
should be removed. 

A long, tapering screw may sometimes be advan- 
tageously used for the extraction of these roots, when 
they are decayed so deeply that an extensive break- 
ing away of the process would be incident to their 
removal with the forceps. The elevator, however, is 
rarely ever called into requisition here. 

Inferior Biciisjyids. — These teeth, two in number 
on each side, have but one root each, and that 
generally round, or nearly so, and not so long as 
that of the cuspids, and have less diameter at 
the neck than they. They require, in extraction, 
forceps for each side, as already described (see Fig. 
105). They may be removed either by the rotary 
or by the inward and outward movement, or both 
combined. With the handle of the forceps thrown 
very far out of a line with the axis of the tooth, 
it is always more difficult to be rotated accurately 
in its socket ; a straight instrument is best for 
the rotary motion. In the removal of these teeth 
from the right side, when the mouth is small, care 
should be taken that too much presstire is not made 
against the anterior tooth. This accident is more 
liable to happen in the removal of the second bicus- 



426 EXTRACTION OF TEETH. 

pid than in that of the first, and especially if the 
mouth cannot be opened wide. As the tooth comes 
out, the forceps are liable, without some attention, to 
strike the superior teeth, and in this way fracture 
them or scale off their enamel. In many cases, for- 
ceps with a forward and an outward curvature com- 
bined would be very desirable, for facility of ap- 
proaching the tooth ; but with such a complication 
of curves, the operator loses control of the instru- 
ment. 

In the removal of the bicuspids of the left side, 
there is little or no liability to undue pressure against 
the anterior teeth ; and in their extraction the move- 
ment should be mainly inward and outward, since 
the great curvature of the forceps renders a rotary 
motion very difficult and uncertain. There is also 
danger of striking the upper teeth, especially if the 
tooth to be extracted comes out with less effort than 
the operator anticipated — an accident that sometimes 
befalls the most skillful and discriminating. The 
first and the second inferior bicuspids are removed 
with about equal facility. 

Occasionally, though seldom, these teeth have two 
distinct, well-defined roots — a condition that cannot 
be determined by the form of the crown, or by any 
other visible indication ; and one tooth alone will 
sometimes be found with this peculiarity. The re- 



EXTRACTION OF TEETH. 42T 

moval of the roots of these teeth is not attended with 
much difficulty, the main consideration being to 
obtain a deep, strong hold on them, and then apply 
a firm, steady movement. 

Inferior Molars. — These teeth commonly have two 
roots, a posterior and an anterior, the latter being the 
largest, and frequently the longest. The roots have 
different inclinations to the axis of the tooth, being in 
some cases divergent from, and in others parallel with 
it, and in others convergent, or curved together so that 
their points almost meet. The forms of the crowns will 
give some indication of the inclinations of the roots. 
If the former are short, the latter are so, and vice versa; 
if the diameter of the crown is about the same at the 
masticatory surface and the neck, the roots do not 
diverge \ if the crown is long, and of uniform 
diameter, the roots will be either parallel or con- 
vergent ; and if the angles on the crown are not 
sharp and well defined, the roots most probably curve 
together at the points. If, however, the angles formed 
by the masticatory and lateral surfaces of the teeth are 
sharp and well defined, the roots generally diverge. 

Forceps adapted to each side are required for the 
removal of these teeth. These forceps have a promi- 
nence, or point, in the centre of the beaks, to pass 
into the bifurcation ; and in separating the gum, it is 
important to dissect it away, and, if need be, even 



428 EXTRACTION OF TEETH. 

cut away the margin of the process, so that the bifur- 
cation may be well exposed, to admit the forceps to 
a proper position on the tooth, without obstruction. 
The tooth being firmly grasped in tbe proper manner 
by the forceps, is moved gradually, but steadily, 
inward and outward, to break up the attachment, 
and then drawn from its socket. In the removal of 
these teeth from the right side with the ordinary for- 
ceps, there is great danger of undue pressure on the 
anterior contiguous teeth ; this is to be avoided by 
directing the pressure backward in the operation. 
And there is also danger of injuring the upper teeth 
with the forceps ; this may be obviated by wrap- 
ping the point of the instrument with a small napkin. 
In the removal of the inferior molars of the left 
side, the application of force is the same — an inward 
and outward movement — but the handles of the for- 
ceps occupy different relntive positions to the teeth 
to be extracted — passing directly out at the front of 
the mouth instead of at one side. In consequence 
of this arrangement, the operator cannot exert the 
same force on them as, with the proper forceps, on 
those of the right side. Very little traction can be 
employed in connection with the oscillating move- 
ment, but the attachment must be almost wholly 
broken up before beginning to lift the tooth from the 
socket. But in extracting the teeth on the right 



EXTRACTION OF TEETH. 429 

side with the proper forceps, traction is always com- 
bined with the inward and outward movement. 

In the extraction of the roots of these teeth, little 
difficulty is experienced after the decay has proceeded 
so far as to effect their separation. They are then 
embraced with the appropriate forceps, and removed 
as single roots are elsew^here. These forceps have 
narrow, thin, sharp beaks, turned to almost a right 
angle. With them the root is embraced and moved 
inward and outward till loosened, and then removed. 
When the mouth is large, and can be opened wide, 
the slightly curved root forceps are convenient, and 
the rotary movement may be employed with them, if 
the roots are not very much curved, flattened, or 
firmly set. The removal of these roots is more diffi- 
cult when the bifurcation is low down, and the roots 
remain firmly attached together, and especially when 
they diverge. If the bifurcation is not too low, and 
the attachment not too firm, the roots may be sepa- 
rated with the separating forceps (Fig. 122), and 

Fig. 122. 




then removed singly, as in other cases. This is the 
preferable method when there is much divergence ; 



430 EXTRACTION OF TEETH. 

but if the roots cannot be separated, they may be 
extracted with the forceps shown in Fig. 122. The 
round, curved, sharp beaks are passed down between 
the roots, and the whole is removed at once ; the 
attachment being broken up on the principle already 
described. 

These teeth sometimes have but one large, round, 
conical root; and there is seldom, if ever, enough 
curvature of the roots to render extraction difficult. 
The ordinary inferior-molar forceps are not well 
adapted for the purpose, for the central points of 
their beaks will prevent a perfect adaptation. The 
broad, single-concave beaked forceps are best adapted, 
the curves and general forms of which, except the 
beaks, are the same as those represented in Fig. 107. 
The removal of teeth having roots of this kind is easily 
accomplished. Rotary movement would be applicable 
here if the exact form of the root could be ascertained 
before extraction; but it is, in general, the safest course 
to employ the inward and outward movement. 

Inferior Third Molars. — These teeth require for 
their removal the broad, single-concave beaked for- 
ceps, the beaks curved at a right angle with the 
handle, and the handle straight. This instrument 
fixed deeply and firmly on the tooth, the attachment 
is to be broken up by the inward and outward move- 
ment. These, more frequently than the superior 



EXTRACTION OF TEETH. 481 

third molars, stand out of the proper position ; their 
variations and the manner of obviating the attendant 
difficulties, however, being about the same — at least, 
so far as deviation is concerned. Physic's forceps 
may be used here with greater facility than on the 
upper teeth. 

These teeth frequently exhibit but a very small 
portion of the crown through the gum. Being 
erupted with an anterior inclination, the tooth comes 
in contact with the posterior portion of the second 
molar, and is thus checked in its external develop- 
ment. Thus the crown is left partially covered with 
the gum, which frequently inflames, and even suppu- 
rates, remaining in that condition for a considerable 
time, to the great annoj^ance of the patient. Such 
teeth are difficult to remove ; first, because of their 
inclination and contact with the second molar ; and 
secondly, because the crown is more than half below 
the borders of the thick, firm alveolus, rendering it 
impossible to obtain a firm hold of the tooth without 
cutting away a portion of the alveolus. In such 
cases, it is generally best to make a free excision of 
the alveolus all round the tooth, sufficient to permit 
its easy removal. 



432 EXTRACTION OF TEETH. 



EXTRACTION PREPARATORY TO THE INSERTION OF 
ARTIFICIAL DENTURES. 

Whenever there is a number of teeth to be re- 
moved, the method and the duration of the operation 
will depend on the following circumstances : 

First. The number to be removed. 

Second. The firmness of their attachment. 

Third. The patient's power of endurance. 

Fourth. The manner in which the immediate parts 
are affected. 

Where the number to be removed is considerable, 
and the attachment feeble, or not very firm, and the 
patient's power of endurance good, the extraction 
may be as rapid as is consistent with efficiency. In 
many such cases, from three to six teeth may be 
removed, without any relaxation by the operator of 
his hold on the parts with the left hand. This is 
generally practicable with the front teeth of the 
lower, and frequently with those of the upper jaw ; 
but it is not proper to remove more than three or 
four of the molar teeth without respite, even when 
they are quite loose, or have but a feeble attachment 
in the socket. The gum should of course be well 
separated previously to the operation. Only so many 
teeth should be removed at one sitting as the nervous 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 433 

system will allow without too great a shock. In 
many instances, however, it is practicable, so far as 
this is concerned, to remove at once all the teeth in 
the mouth. In the extraction of a large number, 
those most easily removed should be first taken, so 
as by degrees to bring the patient to the more severe 
operations. If there is a manifest hemorrhagic 
diathesis — a disposition to bleed freely from the 
capillaries, as well as from the larger vessels — but 
two or three teeth should be removed at a sitting, 
lest uncontrollable hemorrhage ensue. 

After all the teeth are removed from one or both 
of the jaws, the gums and alveolus should undergo a 
trimming process : all detached, flabby, or prominent 
portions of the gums should be dissected off; the 
whole ridge made uniform -, all loose portions of the 
alveolus removed ; all the prominent points and sharp 
edges cut down ; and the whole border of the process 
rendered as smooth and even as possible. By this 
means, the healing of the parts is facilitated, and they 
assume the desired condition and form in much less 
time, and with far less soreness and inconvenience. 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 

Such conditions are often found to exist in the 
system as indicate the necessity of great care in the 



434 EXTRACTION OF TEETH. 

operation, or of prior treatment, or forbid the extrac- 
tion of the teeth altogether. Of these conditions, the 
following are some of the more obvious : 

Extreme debility. 

Great nervous irritability. 

Excessive local inflammation, especially where it 
tends to other parts. 

Much irritability of the parts intimately connected 
with the teeth. 

Pregnancy and all uterine irritations. 

A tendency to epilepsy. 

In many cases, where there is great debility, so 
painful an operation as the extraction of a tooth will 
cause extreme and sometimes alarming prostration. 
This, however, may be anticipated by prior invigo- 
rating treatment, continued till strength and tone are 
obtained sufficient to endure the operation. This 
treatment may occupy considerable time, while an 
urgent case may arise, in which the removal of the 
offending tooth is immediately demanded, in which 
case it is proper to administer stimulants — brandy or 
wine, or such as the case may seem to require. By 
such means the system may be so invigorated as to 
withstand the shock of the operation with compara- 
tive fortitude. 

There is in some cases a highly irritable condition 
of the nervous system, that almost absolutely forbids 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 435 

the extraction of teeth, convulsions being sometimes 
produced in such cases by a simple operation. This 
remark does not of course apply to facial neuralgia, 
that may be either partially or wholly produced and 
kept up by diseased teeth ; neither general nor local 
neuralgia would be aggravated by an operation of 
this kind. Accompanying general nervous irrita- 
bility, there is usually excessive dread of an opera- 
tion, such as to occasion rapid prostration — even 
greater and more rapid than that caused by the ope- 
ration itself. In such cases, if the extraction is 
effected immediately, it will give relief; but where 
the excitement has been very high, and the tension 
for some time great, the depression after the opera- 
tion will be correspondingly great, and considerable 
time be required for complete recovery ; indeed, the 
shock is sometimes so severe as to occasion confine- 
ment for several days. Treatment for quieting the 
nervous system, consisting in agents of a sedative cha- 
racter, may be employed previously to the operation. 
Stimulants, as a general rule, should be avoided. 

Where there is a high state of inflammation in the 
immediate parts, especially if there is a general in- 
flammatory diathesis, the propriety of extracting the 
teeth is questionable. Under such circumstances, 
there is probably less danger in the extraction of the 
inferior teeth than of the superior. Where the inflam- 



436 EXTRACTION OF TEETH. 

mation has a disposition to extend, it is liable to go 
to the head from the superior maxilla, and to the 
fauces and throat from the inferior. In cases, then, 
where there is excessive inflammation in the imme- 
diate parts, accompanied hy a general inflammatory 
condition, both local and general antiphlogistic treat- 
ment should be adopted. 

Extreme irritability, or a diseased condition of 
parts having an intimate connection with the teeth, 
as, the immediate surrounding tissues, the salivary 
glands, and the throat, is a circumstance admonishing 
to great caution in the extraction of teeth, especially 
when such condition does not depend on the teeth 
for its exciting cause or modifying influence. It is, 
however, very generally the case, when any of the 
parts having an intimate relation with the teeth be- 
come in any way affected, that diseased teeth will 
exercise an injurious influence on them. If the neces- 
sity for the removal of the offending tooth is not too 
urgent, the parts that may be diseased about it should 
be brought to as good a condition as possible. 

Pregnancy and uterine irritation frequently pro- 
duce strong sympathetic influences on the teeth, and 
especially on those which are in an irritable condition. 
Even sound teeth may be thus affected, so as to occa- 
sion great annoyance. Such teeth are frequently pre- 
sented for extraction ; but these cases should always 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 437 

be thoroughly examined before deciding as to the pro- 
priety of an operation. As a consequence of this sym- 
pathetic connection between the teeth and the uterus, 
the latter, when in an irritable condition, is very 
liable to be affected by any special violence to the 
former. In many cases, under such circumstances, 
the extraction of a tooth is attended with pain in the 
uterus ; and in cases of pregnancy, where there is de- 
bility of the parts involved, abortion may follow the 
operation. It is the duty of the patient, under such 
circumstances, to notify the operator of the condition, 
or if the latter has any knowledge of it, it is his duty 
to become fully acquainted with the circumstances, 
and then to conform to the indications. In such case, 
treatment will avail but little to prepare the system 
for the operation. The better method is to adopt 
palliative treatment, which, if the aflfection is wholly 
sympathetic, must be directed to the organ producing 
the difficulty. But if the affection is in part local, then 
topical treatment is also indicated. When there is a 
suppression of menstruation, there will be an increased 
disposition to hemorrhage ; and in the extraction of 
the teeth of a patient of hemorrhagic diathesis, this 
is a point to which attention should be very specially 
directed. Here, of course, a remedy for the obstruc- 
tion w^ould meet the difficulty. 

Persons subject to epilepsy should be very cau- 



438 EXTRACTION OF TEETH. 

tiously treated in all operations on the teeth, and 
most especially in their extraction. It is not prob- 
able, however, that an operation of this character 
would increase the tendency to epilepsy ; but any 
undue excitement is liable to produce a paroxysm of 
the disease, and hence the operator should proceed 
to his work with as little parade as possible, yet not 
stealthily; the patient should be thoroughly aware of 
what is to be done; for, of all patients, such a one is 
the last that should be deceived. Of course, in a case 
of this kind, there can be no prior treatment that will 
avail anything ; the most that can be done is, to await 
the fittest opportunity in respect to the paroxysms. 
There is no more liability to fatal results with such 
patients than with others. 



CHAPTER XII. 

ACCIDENTS IN THE EXTRACTION OF TEETH. 

The accidents liable to occur to the teeth and the 
contiguous parts in the operation of extraction were 
formerly far more frequent than at present. This 
results from the existence of more perfect instru- 
ments and of more accurate and extensive knowledge. 
Formerly, very few studied the peculiarities of the 
teeth, either in their physical or anatomical struc- 
ture ; their peculiar forms, as indicated by their 
crowns ; their anatomical and physiological relations 
to the contiguous parts and to one another ; and their 
attachment as affected by the character and structure 
of the tissues about them. The instruments em- 
ployed, too, were, till within a few years past, very 
crude in their forms, very inapplicable in that part 
which embraces the tooth, inappropriate in their 
shapes, and defective in their manner of applying the 
force in the operation. But these causes of accidents, 
so far as the better part of the dental profession is 
concerned, have been in a very marked degree dimin- 
ished. 



440 ACCIDENTS IN THE EXTRACTION OF TEETH. 

Some of the accidents attendant or consequent on 
the extraction of teeth are of a grave character. 
Permanent deformity has sometimes been occasioned 
by extensive laceration of the soft parts, or by frac- 
ture of the alveolus and of the maxilla. Intense and 
protracted suffering frequently, and death sometimes, 
follows such accidents. 



HEMORRHAGE. 

Excessive and obstinate hemorrhage in some cases 
follows the extraction of teeth, occasionally resulting 
seriously and even fatally. There is in some consti- 
tutions a hemorrhagic diathesis, so that from a small 
wound, or even a scratch, there will ensue persistent 
bleeding. This condition is dependent, first, on a 
lack of tone in the blood-vessels, so that they fail to 
contract at an injured or ruptured point ; and secondly, 
on a peculiar condition of the blood, such as to pre- 
vent ready coagulation, as when there is a relative 
deficiency of albumin and fibrin. It is one of the 
most important duties that ever devolve on the den- 
tist, to make a correct diagnosis in cases where there 
is a tendency to hemorrhage. Close attention to the 
following points will assist much in arriving at a just 
conclusion. In persons of a hemorrhagic tendency, 
there is a lymphatic, serous temperament ; a lack of 



HEMORKHAGE. 441 

tone in the soft parts — a soft, flabby condition ; the 
skin pale, and devoid of the bright, vital appearance; 
the eyes and hair of light color; and the flow of 
saliva and mucus abundant. Besides these indica- 
tions, much may be learned sometimes by properly 
directed inquiries of the patient in regard to a dispo- 
sition to hemorrhage on being wounded, either in his 
own case or in that of his relatives ; if in the former, 
under what circumstances ; whether from an exten- 
sive or slight wound ; from large or small vessels — 
from arteries or veins ; or whether it occurred imme- 
diately or after the lapse of some time. If the 
patient has never met with an accident sufficient 
to occasion excessive hemorrhage, and any of his 
relatives have, and a tendency to bleeding is sus- 
pected in the case, the operator should ascertain 
whether there is a similarity of temperament and 
constitutional tendencies between the patient and 
such relative. 

There are certain conditions in which excessive 
hemorrhage would be more likely to occur than in 
others ; as, for instance, when there is an accidental 
relaxation, or deficient tone in the system, especially 
the vascular; and also when there is a suppression 
of any periodical discharges. There may be excess- 
ive hemorrhage from a ruptured vessel when there is 
no constitutional hemorrhagic tendency. There is 



442 ACCIDENTS IN THE EXTRACTION OF TEETH. 

sometimes a local difficulty with the vessels — a lack 
of tone in the part — or an aneurismal condition — on 
account of which obstinate hemorrhage will occur. A 
peculiarity of this kind is not very readily recognized. 
Violent passion, and, indeed, any strong agitation 
of the mind, will aggravate hemorrhage. Improper 
medication, as well as highly stimulating food, will 
have the same tendency. Anything that will in- 
crease the circulation, or reduce the tone of the 
vessels, or change the condition of the blood, will 
increase the liability to hemorrhage. Simple deter- 
mination of blood to a part, however, would not 
indicate such a liability. When there is a special 
hemorrhagic diathesis, the blood will flow from all 
the wounded surface, will be thrown out from all the 
ruptured capillaries. The most difficult cases are 
those in which there is a defect both in the vessels 
and in the blood. If the latter is in a good condition, 
it will coagulate in ruptured capillaries, though they 
might be deficient in tone ; but in larger vessels, 
though coagulum might be formed, it would hardly 
be retained. 



TREATMENT. 

In cases where there is manifest hemorrhagic dia- 
esis, prior treatment is indicated, if the necessity 



HEMORRHAGE — TREATMENT. 443 

of extraction is not urgent; and that treatment will 
be determined by the peculiar condition of the case. 
If there is a lack of tone in the vessels — an inability 
to contract — then the treatment should be of a tonic 
character ; and if the blood is in good condition, this 
is the only treatment necessary ; but, if in a vitiated 
state, other treatment will be demanded, the object 
of which is to produce an increase of red corpuscles, 
albumin and fibrin. It is always better to postpone 
an operation, if at all practicable, till such treatment 
can be had as will bring the system to the best pos- 
sible condition. 

Of the several methods of arresting hemorrhage, 
the proper one in a given case will be determined by 
the circumstances. Styptics or astringents applied 
directly to the ruptured surface will often be found 
to produce coagulation of the blood, and thus stop its 
flow without anything else. This kind of remedy 
will be ef&cient in those cases in which the applica- 
tion will produce contraction of the bleeding vessels, 
as well as coagulation of the blood. Sometimes this 
class of agents will fail to accomplish the object ; in 
which case, in addition to them, compression should 
be made upon the part. Indeed, in many cases, the 
compress will effect all that is desired, without any 
other application. 

There are several methods of applying the com- 



444 ACCIDENTS IN THE EXTKACTION OF TEETH. 

press ; but the one best adapted to any given case 
will be determined by circumstances — such as the 
extent of the wound, the character of the hemor- 
rhage, the location of the injury, and the size of the 
mouth. 

A very common method of making compression in 
the socket from which a tooth has been drawn, is to 
force into the cavity pledgets of cotton, or small 
strips of linen, tightly till it is full. It is well to 
saturate these with a solution of tannin, or some 
astringent preparation, applying it, too, in connection 
with the compression. In some cases, a simple pack- 
ing of the cavity in this manner is quite sufficient; 
but in others it is necessary to retain the pledgets 
in the socket by means of further compression. This 
is effected by placing a roll of linen, or perhaps bet- 
ter, a properly-formed piece of cork, on the packing, 
and then closing the jaws tightly upon this, and, if 
need be, placing a bandage under the chin, and tying 
it firmly over the head. The length of time during 
which it will be necessary to keep the jaws thus 
together will, depending on the nature of the case, 
be from one to six hours. After the hemorrhage has 
entirely ceased, the bandage is to be removed care- 
fully, and the patient instructed to hold the jaws 
together on the compress for a time, and then gradu- 
ally to open the mouth, and remove the cork with 



HEMORRHAGE — TREATMENT. 445 

much caution. After this the packing should re- 
main in the socket from one to three days, and then 
be removed very carefully, one piece at a time, lest 
the ruptured vessels be opened and the hemorrhage 
caused to recur. 

The object in applying a compress is to bring it to 
bear upon the aperture of the wounded vessel, and in 
this way to prevent the escape of blood, till coagulum 
is formed and the opening permanently closed. The 
operator should ascertain the precise point from which 
the blood flows, and form the compress so as to bear 
full upon it. If the flow is from all the wounded 
surface, then the compress must be made to conform 
exactly to that throughout. 

Another method of making the compression, is to 
force softened wax into the socket, so as to fit it per- 
fectly; remove it and chill it in cold water; and then 
introduce and make compression upon it in the man- 
ner already described, following throughout the 
general directions. Another, and probably better, 
method is to form cones of wax cloth, as near the 
shape and size of the root removed from the socket 
as possible. This material is prepared by dipping 
thin linen into melted beeswax, withdrawing it and 
letting it cool, and then cutting off strips of from a 
fourth to half an inch wide, and rolling them to the 
proper size and shape ; having softened this material 



446 ACCIDENTS IN THE EXTRACTION OF TEETH. 

by heat, and freed the socket of coaguhim, introduce 
and press it firmly into place, making the compression 
on it as already directed. This makes a very efficient 
compress for many cases. 

Plaster of Paris is sometimes used on the principle 
of a compress. Having the plaster mixed of the 
proper consistence, and the cavity clear, fill com- 
pletely with it, let it set, and then make compression 
on it in the usual manner. 

The root of the tooth is sometimes returned to the 
socket, to serve as a compress. It possesses the 
advantage of having a perfect adaptation. This 
method of compression may be made more thorough 
by immersing the root in melted wax, and then, before 
this becomes too hard, introducing it into its original 
position. This makes a very perfect and efficient 
compress. If the crown is still remaining, when the 
jaws are closed it will come in contact with the oppos- 
ing teeth, and thus be kept firmly in place, without 
anything further. It may be removed carefully after 
from one to three days. In cases where there is 
hemorrhage from the entire wounded surface, there 
will be a considerable flow of blood from the margin 
of the gum, even after plugging up the socket, and 
making compression by either of the methods de- 
scribed. In such case, after the socket is plugged up 
as already described, a plate is so formed as to fit 



HEMORKIIAGE — TREATMENT. 4.17 

tightly over the gum, and draw its margin down 
closely upon the compress. This pressure on the 
bleeding edges of the gum checks the flow of blood 
there. The plate must be held down by the means 
already described. It is sometimes difficult to obtain 
an accurate fit for the plate, so as entirely to pre- 
vent the blood from continuing to ooze out. In such 
cases, make the plate to conform as nearly as con- 
venient to the part ; then fill up its concavity with 
plaster of Paris, mixed to a proper consistence, and 
then place the whole upon the part, till the plaster 
conforms exactly to it, and retain it there till the 
plaster sets. This is then used for the compress. 
Or the inside of the plate may be thickly coated with 
softened gutta-percha, instead of plaster, and pressed 
upon the part in the manner already described, and 
employed in the same way. 

It will often require considerable discrimination to 
deterrnine the best method of obtaining compression. 
Very great difficulty is occasionally experienced when 
a portion of the process has been broken away, or the 
soft parts have been lacerated. 

Various preparations are used as hemostatics. 
These agents serve to check hemorrhage in two 
ways : first, by facilitating coagulation of the blood ; 
and, secondly, by producing a contraction of the ori- 
fice of the ruptured vessels. It is proper in all cases 



448 ACCIDENTS IN THE EXTRACTION OF TEETH. 

to use styptics in connection with the compress. The 
following agents have been used as styptics : tannic 
acid, creosote, nitrate of silver, chloride of zinc, sul- 
phate of zinc, oil of turpentine, muriate of iron. The 
methods of applying these different preparations are 
the same. The agent is simply to be retained in 
contact wdth the part till it has exerted its influence. 
A solution of tannin in alcohol, w^ith creosote, equal 
parts, makes a very powerful styptic ; or tannin and 
creosote alone is perhaps equally efficient. 

The actual cautery is sometimes used to arrest 
hemorrhage ; but the propriety of using it in cases 
where there is a manifest hemorrhagic diathesis is 
exceedingly doubtful. When the cauterized surface 
is sloughed off, the hemorrhage is liable to recur with 
increased vigor, indeed, is certain to do so in almost 
every case wdiere there is a strong predisposition. 
Constitutional treatment may be employed to antici- 
pate hemorrhage ; and it should have in view an 
increase of the relative amount of red corpuscles, 
albumen, and fibrin in the blood, and also the produc- 
tion of a normal tone of the system. Saline purga- 
tives may be used with very decided advantage, 
followed with acetate of lead, in connection with 
opium, the effect of the lead being to increase the 
coagulability of the albumen and fibrin. Care should 
be exercised, how^ever, in its administration. 



HEMORRHAGE — TREATMENT. 449 

Excessive hemorrhage will sometimes occur from 
very slight wounds ; death has been known to ensue 
from simply scarifying the gums. 

Mr. C. desired the removal of the first superior 
molar. The gum was separated from the neck of the 
tooth with the lancet, in the usual manner, when he 
refused to have anything further done, and left the 
office, there being a slight discharge of blood from 
the gum. After a few hours, the hemorrhage in- 
creased, so as to cause alarm to his friends. The 
patient was about eight miles from a dentist, and a 
physician of rather moderate skill was called to the 
case. He probably acted according to his best know- 
ledge, but failed to arrest the hemorrhage, and suc- 
ceeded in convincing the friends that no one else 
could do better. The flow of blood continued three 
to four days, proving well-nigh fatal, but at last 
abated, and the patient recovered. In this case, a 
properly-directed compress would have checked the 
bleeding in a few minutes. 

Another case : Mrs. T. had nine teeth removed. 
The operation was not followed immediately by un- 
usual hemorrhage, but within two or three hours the 
flow of blood had increased to an alarming extent, 
so as to run from the mouth in a continuous stream. 
The indications were that the patient would soon die. 
She had become very weak. On examination, the 



450 ACCIDENTS IN THE EXTRACTION OF TEETH. 

blood was found issuing only from the socket of one 
root of an inferior molar. The mouth and socket 
being cleansed of blood and coagulum, it was perceived 
that the hemorrhage was from a small artery at the 
bottom of the socket, spouting out in jets with the 
pulsations. The treatment consisted in rolling up 
pledgets of cotton very tightly, saturating them with 
creosote and tannin, and forcing them in on the 
bottom of the socket, so as to make compression 
upon the bleeding vessel. The socket was then filled 
up, compression made, and the head bandaged in the 
manner already described. Thus the hemorrhage 
was immediately checked, and did not return. The 
constitution of this patient was of a scorbutic dia- 
thesis. 

Excessive bleeding often does not occur till a con- 
siderable time after an operation ; and it may come 
on without any exciting cause, or be induced by 
vigorous muscular exercise, or by any intense mental 
excitement. Everything of this kind should be 
avoided where there is a predisposition to hemor- 
rhage, and everything invited that would tend to 
maintain the equilibrium of the circulation and the 
utmost quiet. 



FRACTURE OF THE ALVEOLUS. 451 

FRACTURE OE THE ALVEOLUS. 

The ordinary fracture of the alveolus is a matter 
of no considerable consequence, if it receives proper 
attention. This fracture occurs to a greater or less 
extent under the following circumstances : 
. First. When there is great divergence of the roots, 
so that the tooth cannot pass from its socket, unless 
one or more of them are broken off, or the alveolus 
is fractured. 

Second. Where the tooth is forced out of the socket 
at a very considerable angle with its axis. 

Third. Where the alveolus is very firmly attached to 
the roots, and is very thin toward the point of these. 

Usually, the fracture is of that part which forms 
the socket of the tooth removed ; and when this is 
the case, it is of but small moment. It sometimes, 
however, extends far beyond this, involving the 
alveolus of from one to four of the adjacent teeth, 
and causing very serious injury, even the loss of the 
teeth themselves. Extensive fracture, however, is 
far less liable to occur now than when less perfect 
instruments were employed. When the key was 
in general use, extensive fracture of the alveolus was 
frequent ; but with the forceps, it is comparatively 
rare. 

When an accident of this kind does occur, all of 



452 ACCIDENTS IN THE EXTRACTION OF TEETH. 

the detached portion, whether large or small, should 
be removed. A pair of bone nippers, or enucleating 
forceps, will answer for this purpose. If there is 
much attachment of the soft parts, it should be dis- 
sected off, and then removed. If such fractured por- 
tions are permitted to remain, inflammation, and 
oftentimes sloughing of the gums, will ensue ; necrosis 
of the bone is also sometimes produced by detached 
bone remaining in contact with the living. 

Sometimes extensive fracture occurs, involving the 
adjacent bony structure. In the case of Mr. W., in 
an effort to remove the first superior molar, the outer 
wall *of the alveolus was separated from the other 
teeth. The fracture extended almost to the zygo- 
matic process, and detached a portion of the floor of 
the antrum, as well as a part of its outer wall. After 
the removal of this detached portion, there was a 
considerable external depression, that very much 
marred the form and symmetry of the face. 

Fracture of the alveolus should always be guarded 
against as carefully as possible. It always makes an 
unfavorable impression on the mind of the patient, 
which in many cases no explanation can obliterate. 
Whenever the accidcDt does occur, the disagreeable 
knowledge of it may, if practicable, remain a secret 
with the operator. 



BREAKING THE TEETH. 453 



LACERATION OF THE GUMS. 



The gums are often bruised and lacerated with the 
key in the extraction of teeth. But this accident 
seldom happens with the forceps ; indeed, never, un- 
less the gum is very firmly attached to the neck of 
the tooth, and has not been separated with the lancet. 
The gum will sometimes be lacerated by adhering 
to a piece of the process while the tooth is drawn 
from its socket, with the process and gum attached. 
With the various hooks and punches, the gums, lips, 
and cheeks are sometimes wounded. Accidents of 
this kind are to be prevented by placing a finger of 
the left hand, or a guard made of a roll of linen, in 
front of the instrument. When any considerable 
portion of gum is lacerated, the detached portion 
should be cut off. The worst consequences from 
laceration of the soft parts occur where there is a 
hemorrhagic diathesis. The most effectual means 
of preventing accidents of this kind is to separate the 
gum perfectly, and guard well the points of the 
instrument. 

BREAKING THE TEETH. 

This is an accident of no small consequence, and is 
liable frequently to occur in the use of imperfect, illy- 



454 ACCIDENTS IN THE EXTRACTION OF TEETH. 

adapted instruments, or in the unskillful use of good 
ones. It is of very common occurrence when the key 
is employed for extracting, even in the hands of 
those who claim to be skilled in its use. And with 
forceps, too, of the primitive form, the teeth were so 
frequently broken, as almost to preclude their use as 
extracting instruments. This accident usually occa- 
sions great pain to the patient, as well as protracts 
the operation, and diminishes his confidence in the 
ability of the operator. One such accident will 
create more prejudice than fifty skillful operations 
can obliterate. 

In all cases where a tooth is broken, the root, if 
possible, should be removed ; for if it be not, con- 
tinuous or periodical pain, inflammation, alveolar 
abscess, and like affections, are liable to ensue. The 
remark is often made, when teeth are broken, that 
the gums will close over the roots, and thus effect- 
ually protect them, and no disagreeable consequences 
will follow. In no ordinary case will the gums 
unite over even the smallest portion of root that 
may have been left in the socket. 

REMOVAL OF A WRONG TOOTH. 

There is very rarely any excuse for the removal of 
a sound, healthy tooth in the immediate vicinity of a 



REMOVAL OF A WROXG TOOTH. 455 

diseased one, unless it be in a case of those deep- 
seated, hidden affections which are difficult to diag- 
nose. It sometimes happens, however, that a sound 
tooth is removed ; and when a mistake of this kind 
is made, the diseased tooth should also be at once 
removed, and then, if the conditions are favorable, 
the healthy one should be immediately replaced. 
The circumstances most favorable for such replace- 
ment are a good constitution in a state of health, and 
a normal condition of the mouth, especially of the 
gums and mucous membrane, so that the attachment 
would take place with as little inflammation and 
soreness as possible. If the tooth is necessarily kept 
out of the mouth many minutes, it should be placed 
in water at about blood heat ; and before the replace- 
ment, the socket should be thoroughly cleansed of 
coagulum. The tooth is then introduced, pressed 
firmly to place, and allowed to remain, without dis- 
turbance or irritation, till the attachment has become 
complete. During the time it is reuniting, treatment 
may be required to counteract inflammation. Meagre 
diet, abstinence from stimulants, and quiet, should 
always be recommended in the case. 

This operation has been wholly condemned by some 
very good dentists. Dr. Koecker declares that it 
should never be attempted. But numerous success- 
ful cases, well attested, give assurance that it may 



456 ACCIDENTS IN THE EXTRACTION OF TEETH. 

very frequently be accomplished with the most satis- 
factory results. Mr. T., aged fifteen years, of good 
constitution, and in good health, and with the mouth 
principally in a normal condition, had the second 
inferior bicuspid of the left side removed by mistake, 
the first molar being the offending tooth. The former 
was at once put into cold water, and the latter forth- 
with extracted. The socket of the bicuspid was then 
cleansed, and the tooth replaced. There was slight 
soreness for a few days, after which the tooth was 
found to have made a firm and permanent re-attach- 
ment, and from that time to this — thirty-three years — 
it has remained perfect, and is now as healthy, life- 
like, and valuable as any other tooth in the mouth. 

Since the issue of the first edition of this work, 
many cases have come under the observation of the 
writer in which detached teeth have been replaced, 
and become as firmly fixed in the sockets as before re- 
moval, and remained in apparently a healthy condition 
so far as the attachment is concerned. In some of 
these cases very unfavorable conditions were present. 

So numerous and successful have these cases been, 
that the feasibility of replacing teeth that have been 
improperly removed is a matter no longer to be con- 
troverted, and especially when favorable conditions 
exist — good health and tone, both general and local, 
and the parts involved not too much fractured or 
lacerated. 



DISLOCATION OF THE INFERIOR MAXILLA. 457 

DISLOCATION OF THE INFERIOR MAXILLA. 

The dislocation of the inferior maxilla is an acci- 
dent of not very frequent occurrence. In persons of 
lax muscles and with large mouths, the operation of 
extracting teeth is liable to produce it — sometimes 
when the operation is on the upper jaw, but more 
frequently when it is on the lower. In the former 
case, it is a result of the patient's effort to open the 
mouth ; but in the latter, generally that of the move- 
ment of the jaw by the instrument. The dislocation 
consists in a downward and forward movement of 
one or both of the condyles, so that they are thrown 
out of their sockets, and rest in front of the anterior 
rim. In such case, the mouth is distended to its 
utmost, the chin thrown down on the breast, and 
deglutition and speech rendered impossible. Some- 
times but one condyle will be thrown out, in which 
case the jaw is thrown downward and to one side. 

This accident seldom or never occurs with patients 
who have small mouths or firm muscles. When it 
does happen, however, the dislocation should be 
promptly reduced. Of the various methods of accom- 
plishing this reduction, the one most commonly em- 
ployed, which is very efficient, is as follows : If both 
condyles are dislocated, place corks or some similar 



458 ACCIDENTS IN THE EXTRACTION OF TEETH. 

substance between the superior and the inferior molar 
teeth of both sides, and then, with the fingers of 
both hands, make firm, steady pressure on the chin 
upward and backward, thus forcing the condyles 
downward and backward into their proper places. 
If but one condyle is out, the cork should be 
applied only on that side, and in the manner already 
directed. Another method is, to substitute the 
thumbs of the operator for the corks, placing them 
in the same position between the teeth, and manipu- 
lating with the fingers on the chin, as before. The 
patient should be placed in a recumbent position for 
the operation. Another method is, to make down- 
ward and backward pressure on the coronoid process, 
and in this manner cause the condyles to glide into 
their places. This accomplishes the reduction with- 
out taking hold of the jaws, or placing a fulcrum 
between them. 

This accident is far more liable to occur the second 
time in the same case. In extracting the lower molar 
teeth for a person who has suffered a dislocation, or 
is predisposed to it, the lower jaw should be very 
firmly supported with the left hand ; or the accident 
may be prevented by placing a bandage under the 
chin and over the head, so that the mouth cannot be 
opened to its furthest extent ; and this is the surest 
method. In all cases after an accident of this kind, 



SYNCOPE. 459 

the patient should ahstain from solid food for a few 
days, or at least till the soreness is abated, and avoid 
everything promotive of inflammation. 



SYNCOPE. 

Syncope, or fainting, is frequently brought on by 
extraction of the teeth, and even by other operations 
upon them ; indeed, it is sometimes produced simply 
by cutting the gums, or by the sight of blood, or, in 
some instances, by dread of an operation. It con- 
sists in an intermission of the heart's action, and 
consequent irregularity of the circulation, accom- 
panied with a temporary suspension of the functions 
of the brain, and a loss of consciousness. Difficult 
or suspended respiration, pallor of the skin, and 
inability to move, are the external indications of the 
condition. There are no constitutional appearances 
known by which a predisposition to syncope can be 
determined. Persons of all apparent conditions and 
peculiarities are subject to it. The most strong, 
robust, and healthy sometimes faint under the most 
trivial influences, while others, of the weakest and 
feeblest constitutions, cannot be brought into this con- 
dition by any ordinary means ; so that nothing can be 
predicated of appearances as to such predisposition. 
The fainting may occur once or twice in the same 
case, even under the most simple operation, owing to 



460 ACCIDENTS IN THE EXTKACTION OE TEETH. 

some temporary condition of the system, and never 
happen again under any circumstances whatever. 

It sometimes comes on before, sometimes after, and 
sometimes during, the operation. There is greater 
liability to it after a recent meal than after digestion 
is completed, since the nervous energy during diges- 
tion is directed to the stomach and its appendages, 
and thus the circulatory apparatus has less of nervous 
force. 

The frequent occurrence of syncope indicates a 
constitutional predisposition to it, and may enable the 
operator to anticipate it to some extent, by the aid 
of stimulants, such as brandy, or, what is in some 
respects preferable, a galvanic current. The patient 
subject to such affection should be placed, for an 
operation, as nearly as practicable in a recumbent 
position, — especially for the extraction of teeth, — 
and his mind kept as tranquil as possible. 

To restore the patient from syncope, place him in 
a horizontal position, the head quite as low as the 
body, and apply volatile stimulants to the nostrils, 
and dash water on the face and chest. All compres- 
sion should be removed from the body, especially 
from the chest, as it would constrain the action of 
the respiratory muscles. This remark is peculiarly 
applicable to female patients. This treatment will 
usually be quite sufficient to effect a rapid reaction 
and resuscitation. 



CHAPTER XIII. 

ANESTHETICS. 
ETHER CHLOROFORM NITROUS OXIDE. 

Sulphuric ether was the first agent successfully 
employed for producing insensibility to pain during 
surgical operations. It was brought to the notice of 
the profession in 1846, by the late Dr. Horace Wells, 
of Hartford, Conn. 

The mode of administering it is by inhalation of 
the vapor ; and it produces its effects in a short time, 
depending on the quality of the ether, the amount of 
air introduced with it, and the susceptibility of the 
patient. A complicated instrument, denominated an 
inhaler, was first employed for its administration ; 
but it soon became apparent that this was not at all 
necessary, and that simpler methods were preferable, 
because more easily regulated and adapted to vary- 
ing circumstances. The best method is to inhale it 
from a sponge or napkin, since in this way the 
admission of the air can be controlled entirely by the 
will of the operator, graduating it to the require- 
ments of the case. 



462 ANESTHETICS. 

During the administration, the patient should be 
in a reclining posture ; though it is held, by good 
authority, that a horizontal position is the safest, 
because in that the force of the circulation is most 
nearly equalized. In the administration of general 
anaesthetics, the circulation is always more or less 
affected. It is an opinion very generally received, 
and probably correct, that where there is functional 
derangement of the heart, lungs, or brain, general 
anaesthesia should not be employed. This opinion, 
however, is perhaps derived more from analogy than 
from actual observation. It is true that, other things 
being equal, the liability to injury in such case would 
be greater; but the danger with both ether and chlo- 
roform is, that there are cases in which there is an 
undefinable and undetectable idiosyncrasy, or mal- 
susceptibility of its influence, to a great extent inde- 
pendent of pathological conditions. 

The patient having been placed in a comfortable 
position, and his mind freed as far as possible from 
apprehension, he should be directed to breathe tran- 
quilly by full inspirations, carefully guarding against 
any compression of the chest, so as to allow the re- 
spiratory mu&cles free play. During the administra- 
tion of the anaesthetic, a strict watch must be main- 
tained over the patient, having reference to the fol- 
lowing points : The breathing should be free and 



ETHER — CHLOROFORM. 463 

easy, a\ ithout irritation of the throat or bronchia ; the 
skin should not become blanched, but should retain 
a florid, lively color ; but the great criterion is the 
pulse, and the indications given here should be 
strictly observed and obeyed. In order that the 
operator may follow every indication, he should be 
familiar with the manifestations of the pulse in diffe- 
rent constitutions and under different circumstances. 
During the administration of ether or chloroform, the 
pulse usually becomes more frequent ; but it should 
not be much accelerated, nor its strength and fullness 
be much diminished. Enfeebled or irregular pulse 
should in all cases be regarded as a warning ; and if 
the feebleness and ii'regularity be very marked, the 
operator should desist. In some instances death 
has occurred after a few inhalations • but perhaps 
only in the use of chloroform. This fact indicates 
that the first effects of the administration should be 
very closely noted. 

The degree to which the anaesthesia should be car- 
ried is a matter about which there is much diversity 
of opinion. Every condition of it, from that of simple 
aUayed irritability to that of complete insensibility 
and unconsciousness, has its advocates. But the 
extent to which the administration may be carried 
will be suggested by the indications already referred 
to, and^ if these are unfavorable, should be deter- 



464 ANESTHETICS. 

mined at once. Mere nausea, however, without any 
other unfavorable symptom, is not a counter-indica- 
tion in the use of ether or chloroform. 

The method of administering chloroform is the 
same as that for ether, except that in the use of the 
former more care and closer observation are required. 
Chloroform is more rapid and powerful in its action 
than ether, and hence more liable to do injury ; but, 
independently of this fact, it is generally believed 
that the former is less safe than the latter, when 
taken into the system, especially by inhalation. A 
mixture of ether and chloroform, or chloric ether — 
usually equal parts of chloroform and ether, but the 
proportions are sometimes varied — is used by some, 
the object being to secure greater promptness than 
with ether alone, and incur less danger than with 
chloroform ; and it is probable that a mutual compen- 
sation in these respects is thus to be attained. 

If either chloroform or ether has been administered 
to entire unconsciousness, the patient should be per- 
mitted to pass out of the condition spontaneously ; 
for after such a revival there will be less liability to 
unpleasant feelings, as headache, depression, and 
nausea. The fingers of the person administering the 
chloroform should be kept on the carotid, since the 
state of the circulation will be better recognized by 
this than by the radial artery, and it is a more con- 



ETHER — OHLOROFORxM. 465 

venient point for observation. In favorable cases, it 
is preferable to continue the inhalation till there is 
muscular relaxation. 

When a condition arises in which respiration is 
suspended, and the circulation partially or altogether 
stopped — a condition of imminent peril — active mea- 
sures must be resorted to for the patient's restoration. 
Efforts must be directed to a recovery of the circula- 
tion, by friction, motion, etc. ; but to restore the 
respiration, is the first, immediate, imperative con- 
sideration. Any or all of the ordinary methods of 
re-establishing suspended respiration may be em- 
ployed. Cold water should be dashed in the face, 
and on the throat and chest, and volatile stimulants 
applied to the nostrils ; the glottis should be titillated 
with a feather, or some such implement, to excite it 
to action ; and artificial respiration, by some approved 
method, should be at once adopted. The galvanic 
current, too, may be brought into requisition, to 
excite the respiratory muscles to action, and to act 
also upon the circulation. In all cases of accident of 
this kind, prompt and efficient measures should be 
immediately taken, for a delay of a few moments 
may be attended with fatal results. 



£E 



466 ANESTHETICS. 

NITROUS OXIDE. 

Nitrous oxide is now used as a general anaesthetic 
quite extensively in dental practice. This agent, 
when properly prepared, and judiciously administered, 
is perhaps the safest general anaesthetic in use; it is 
very efficient for minor surgical operations, and we be- 
lieve it will ere long be found applicable to the more 
protracted and graver operations. Its efficiency is 
very much modified by its preparation and mode of 
administration. This gas when pure is colorless, and 
of slightly sweetish taste and odor ; it is usually pre- 
pared by decomposition of nitrate of ammonia. 

It is not the purpose here to describe the method 
of preparing this agent — that has been well done by 
others ; yet it is proper to suggest here that, to a 
large extent, the knowledge and opinions entertained 
on this subject have been very circumscribed, and 
exceedingly erroneous. In the administration of 
nitrous oxide as an anaesthetic, great care should be 
exercised to secure the best results. In order to 
accomplish this, it should be inhaled, and in no case 
but once, diluted, as circumstances may indicate, more 
or less with pure atmospheric air ; this is ordinarily 
necessary only at the beginning, for pure nitrous 
oxide will sustain respiration for an indefinite time. 

To a patient in an anaesthetic state, it is not so 



NITROUS OXIDE. 467 

readily administered as chloroform or ether ; but the 
patient under its influence is quite as manageable as 
with any other agent, and the anaesthesia as perfect, 
but not as prolonged without continued administration. 

It is scarcely justifiable in ordinary dental practice 
to use a more heroic general anaesthetic than the one 
here referred to. 

Nitrous oxide gas is now prepared in liquid form, 
and may be procured of the manufacturers, ready for 
use. There are some advantages derivable from 
this. The gas in this form is prepared by persons of 
extended knowledge and experience in chemical 
work, which gives assurance of purity ; and, in addi- 
tion to this, by the condensation to the liquid form, 
any extraneous gases are expelled, and thus there is 
far greater certainty of obtaining pure gas than when 
it is prepared in the ordinary way, and that by per- 
sons having little or no knowledge of chemical science 
or processes. 

The accompanying cut represents an ornamental, 
convenient and efficient gas holder. The liquid gas 
is contained in the cylinder in the lower part ; from 
this the gas escapes into the holder above, directly 
from which the gas is administered to the patient. 
A portable apparatus for holding and administering 
the gas is also constructed, which for some purposes 
is preferable to this. 



468 



ANESTHETICS. 
Fig. 123. 




LOCAL ANESTHESIA. 



Because of the frequently prejudicial and sometimes 
fatal consequences to which systemic anaesthesia is 



LOCAL ANiESTHESIA. 



469 



liable^ local ansesthesia lias been brought into requi- 
sition ; the first method of accomplishing this was by 

Congelation. — Freezing a part, to produce insensi- 
bility under surgical operations, is a process that has 
long been in use. Various methods for accomplishing 
it have been employed. There are perhaps none so 
well adapted to the artist's use as ether spray. So 
easy of application is it, and so generally efficient, 
that it is in almost universal use. To Dr. Richard- 
son, of London, is due the credit of having brought 
this process to its present state of perfection. 

So accurately does the accompanying engraving 
(Fig. 124) represent the apparatus used in this pro- 

Fig. 124. 




cess, that a minute description is unnecessary. The 
mode of application and operation is apparent at 
once. 

The instrument consists of the fluid holder — a 
four-ounce bottle, graduated — the bellows consisting 



470 * ANESTHETICS. 

of a rubber ball, with the proper valves, and the 
points from which proceed the spray, and these all 
connected by the proper-sized flexible tube. 

It will be observed that there are variously-formed 
points, single and double, straight and curved ; these 
are required for the various processes to which the 
instrument is applied. 

For the extraction of teeth, the double point is 
applicable, throwing a jet upon the gum each side 
of the tooth at the same time. The . single points 
are required where an incision or excision is to be 
made. 

This is a very valuable instrument, and is exten- 
sively used in minor surgical operations, and is espe- 
cially adapted to the dentist's use. Ether is perhaps 
as yet the best agent employed. Rhigolene, a far 
more volatile fluid than ether, has been used to a 
limited extent, but owing to its exceedingly rapid 
evaporation, its action is too violent, and not so 
easilv controlled. 

For inducing local anaesthesia, various prepara- 
tions have been suggested. The following has been 
in use for several years, namely, a mixture of chloro- 
form, tincture of aconite, belladonna, and opium. 

This applied to the gums, or, indeed, to any other 
surface tissue, will in many cases very much obtund 
sensibility, and in some relieve it altogether, so that 



LOCAL ANESTHESIA. 471 

a tooth may be extracted, or a deep incision made, 
without pain. 

The dental pain obtunder which was introduced to 
the profession about three years ago, for relieving 
sensitive dentine, is a good local anaesthetic. Another 
preparation, made and introduced by Dr. C. Von 
Bonhorst, is also quite efficient. 

Dr. Yon B. has invented an instrument for using 
his preparation, or any other for like purpose. It 
consists of two small metallic cups, attached to the 
ends of an elongated staple, of heavy wire, about 
seven inches long. This is the handle of the appli- 
ance. 

The sponges are placed in sections of rubber tube, 
about half an inch in length, and these together are 
placed in the cups. The sponges are saturated with 
the anaesthetic fluid that may be selected, and are 
applied to the gum on each side of the tooth to be 
extracted, and retained on the part from one half to 
two minutes ; the length of time will be governed by 
the susceptibility of the part, the agent employed, 
and the extent of the ansethesia sought. 

Entire insensibility to pain cannot thus always be 
obtained, but in many cases it can, and diminution 
of it in all cases can be effected. This appliance 
is very convenient for the purpose for which it is 
used. 



472 



ANESTHETICS. 



The following cut (Fig. 125) represents the instru- 
ment ready for use. 

(Fig. 125.) 




EXTRACTION BY ELECTRO-MAGNETISM. 

The employment of electro-magnetism in the ex- 
traction of teeth was introduced to the profession 
about fifteen years ago, and at one time was exten- 
sively used. There is a great diversity of opinion as 
to its efficiency for relieving pain; for, while some 
have been disposed to assume that, when properly 
employed, it would in the majority of cases mitigate 
pain, and in many obviate it altogether, others, after 
having thoroughly tested it, as they affirm, maintain 
that it does not produce insensibility to any appreci- 
able extent, and consequently does not relieve the 
pain, but that, at most, it only complicates the sensa- 
tions, the pain of the tooth-drawing becoming in- 
volved in the confusion of other feelings, so that the 
patient can hardly decide whether he has been defi- 
nitely hurt or not. 

In using this agent for the purpose of extracting 
teeth, the susceptibility of the patient to its influence 



1 



I 



APPLICATION. 473 

must be carefully regarded. Some persons are so 
peculiarly constituted that an electric current is 
almost intolerable to them, while others will receive 
a strong current with pleasurable sensations. To the 
former, the electricity would be as painful as the ex- 
traction of the tooth ; but to the latter, when properly 
applied, it mitigates, and in many cases altogether 
obviates, the pain. The reason of this difference in its 
action is not very clearly understood. Several theories 
in regard to it have been advanced, but none of them 
sufficiently plausible to challenge conviction. 

Again, the manner in which, and the condition of 
the parts to which, this agency is applied, are to be 
closely observed. Where there is acute periostitis, an 
electric current, even though feeble, would produce in- 
tense pain, and should not be applied ; though in such 
cases it has been suggested that an application of the 
charged sponge to the gums will produce insensibility. 

APPLICATION. 

The method of application is very simple. Any 
ordinary battery, of convenient form, may be em- 
ployed for this purpose. It should be uniform in its 
action, and the vibration as short as possible. The 
common zinc-and-copper battery, with the sulphate- 
of-iron solution, is perhaps the most convenient and 



474 AlST^STHETICS. 

safe. One pole of the battery — no matter which — is 
attached to the forceps, and the other to a handle of 
size and form convenient for the patient to grasp. To 
ascertain his susceptibility, the current should always 
first be tested on the patient, by placing the handle 
and the forceps one in each of his hands, and letting 
it on first feebly, and then gradually increasing it till 
he experiences the sensation just beyond the elbows ; 
when, finally, it is to be slightly weakened. The 
gum having been separated, the forceps, with its 
appendages, is adjusted to the tooth, the connection 
made by placing the handle in the patient's hand, and 
the tooth at that moment removed. It has been re- 
commended by some to place the forceps on the tooth, 
and complete the circuit as above, with the current 
very feeble, and then gradually increase it to the 
proper force for the operation. In some instances, 
perhaps, this would be the preferable mode. 

Another method of producing insensibility by an 
electric current is, to place two moistened sponges, 
connected with the two poles of the battery, on the 
gum, one on each side of the tooth, keep them there 
a few moments, and then operate. This method, 
however, has not yet been sufiiciently tested to 
ascertain its merits. 



APPENDIX. 



In the following pages are presented a few subjects, more at 
length than is practicable or desirable in the body of the work. 

Section A. consists of selections from •' Watt's Chemical 
Essays" on " Caries of the Teeth." 

This is perhaps the most accurate and concise presentation of that 
subject in the English language. In treating of the subject, it 
deals with established principles and with facts, and discards all 
mere hypothesis, which has commonly entered so largely into the 
discut-sion of the subject. A careful and thorough study of the 
subject, as here presented, is suggested. T. 

SECTION" A.— DENTAL CARIES. 

It is now admitted, by all who are familiar with the subject, 
that, whatever may be the predisposing causes, the immediate cause 
of dental caries is chemical action. It is well known that consti- 
tutional causes have much to do with this disease, both in pro- 
ducing badly-organized, defective teeth, and in eliminating or pre- 
paring the agents which act chemically on them. But no consti- 
tution produces teeth so defective that they undergo spontaneous 
decomposition while retaining a vital connection with the general 
system. I am aware that a few pathologists still maintain that 
inflammation of the bony texture of the teeth is liable to the same 
terminations as inflammation of ordinary bony tissue ; but it is not 
profitable to debate this point in the present paper. Suffice it to 
say that the structui'e and position of the enamel indicate that the 
dano-er is from without, not from within. 



476 APPENDIX. 

As soon as it is admitted that decay of the teeth results from 
chemical action, it is natural to inquire what agent or agents pro- 
duce this action. Accordingly we find the profession turned at 
once in this direction. And when the composition of the teeth is 
taken into the account, we would infer that the deleterious agents 
are to be looked for among the acids. And here we have had 
great confusion of ideas, and are still likely to have it. For 
example, we are told " that it is proven that nearly all the acids, 
both mineral and vegetable, act readily upon the teeth." {Harris' 
Dictionary/, article " Caries of the Teeth.") Upon any part of the 
teeth ? Or are we to understand that some of them act on the 
animal portion, some on the earthy, and some, or all, on the enamel ? 
Just turn to the index of almost any chemical text-book, and ask 
yourself if it is proved that nearly all of the acids there named act 
readily upon the teeth. Do carbonic acid, tannic acid, and scores 
of others that might be named, act readily upon the teeth ? This 
expression, and many others that might be quoted from various 
writers, show a professional longing for, rather than an attainment 
of, the truth in regard to this matter. 

Now, for convenience, let us assume that dental caries is pro- 
duced by the action of acids. The question still arises, what acids? 
Are many acids, or only a few, concerned in its production ? One 
of the laws of combination teaches us that chemical compounds are 
definite in their nature. Chemical action is always definite. When 
an acid combines with an alkali, or base, a definite compound, 
called a salt, is formed. When a difierent acid unites with this 
same base, a different salt is formed. Each salt, each chemical 
compound of any kind, is distinguished from all others by char- 
acteristics peculiar to itself It is unlike all other substances, in 
some respects. Each chemical result diffiers from all other chemi- 
cal results. Of course, then, a great variety of chemical reagents 
will produce a great variety of chemical reactions. 

Let us now inquire as to the various characteristics of those 
chemical actions which result in what we recognize as dental caries. 
Do we here find a great variety of appearances ? Or is it not well 
known that the phenomena of caries are so few, and so circum- 
scribed, that by common professional consent, but three or four vari- 



DENTAL CARIES. 477 

eties of it are recognized ? We fiad one variety often called " white 
decay," and another that is brownish in color, and a third that is 
very properly designated as " black decay." These differ in other 
respects as well as in color. In the white variety all the com- 
ponents of the teeth are acted on, and disintegrated, as far as the 
disease extends. In the second variety, the earthy portion of the 
teeth seems to be removed, while much or all of the animal portion 
remains, which is conclusive evidence that the chemical agent, 
whatever it may be, forms soluble compounds with the earthy 
materials. In the " black decay" there is less disintegration of the 
tooth substance than in either of the other varieties ; and it pro- 
gresses less rapidly than either of them. The physical character- 
istics of this variety, aside from the chemical, would indicate that 
the chemical agent principally concerned in its production forms, 
mainly, insoluble compounds with the constituents of the tooth. 
Then, there is a fourth variety, commonly called " chemical abra- 
sion," in which the entire tooth-substance is removed, as far as the 
disease extends. It is evident that the agent producing this, dis- 
solves or forms soluble compounds with both the animal and earthy 
materials of the tooth. 

Unless we conclude that chemical compounds are not definite in 
their nature, and that many reagents may produce but a few reac- 
tions, we are forced to the conclusion that dental caries, as observed 
and recognized, results from the action of but few substances on 
the teeth. It is very probable that each distinct variety is pro- 
duced by the action of a single agent, and invariably by the same 
agent. I am well aware that more than one variety may be found 
in the same mouth at the same time, and in close proximity ; and, 
consequently, any given case of caries may partake of the charac- 
teristics of more than one variety. It is not uncommon to find 
" white decay" attacking a tooth in a cavity primarily affected with 
the brown, or colorless variety. But every practitioner is familiar 
with unmixed cases, representing all the four classes specified. 

The physical characteristics of decay depend much on the tex- 
ture of the teeth affected; but they are dependent, also, on the 
nature of the compounds formed by the union of the destroying 
agent with the constituents of the teeth. The degree of concen- 



478 APPENDIX. 

tration of the chemical agent has also a modifying influence. 
When much diluted, its action is almost solely in obedience to its 
strongest affinity. For example, if nitric acid were the agent, when 
concentrated it would act energetically on the animal as well as on 
the earthy materials of the teeth ; but when much diluted, its action 
would be almost confined to the latter. 

The chemical characteristics of decay, however, depend almost 
exclusively on the character of the agent producing it. The truth 
of this appears evident when we reflect that bad teeth and good 
ones are composed of the same chemical substances. Marble and 
chalk are alike in chemical composition, but not in physical struc- 
ture; and though an acid acts more rapidly on the latter than on 
the former, yet the result of the action is the same. An acid, too, 
will act with more energy on a soft, porous tooth, than on one of 
firmer texture; yet the chemical results are the same. It is safe 
to conclude, then, that as there are but few results in the chemical 
actions attendant on dental caries, there are but few chemical 
agents immediately concerned in their production. 

It is not to be inferred from the above that but few agents are 
capable of injuring the teeth by chemical action. Many acids 
used in food or as medicines are capable of doing injury to the 
teeth. But no one need suppose that an acid, even though con- 
siderably concentrated, brought occasionally in contact with the 
teeth, is the immediate cause of caries. Every close observer will 
conclude that caries is the result of an agent acting slowly and 
steadily in the accomplishment of its work. He will be apt to infer 
that this agent is either formed by chemical action within the 
mouth, or is eliminated therein, either as a secretion or an excre- 
tion, and that it quietly performs its disastrous deeds as fast as 
formed or eliminated. The application to the teeth of an acid 
capable of acting chemically on them, facilitates or predisposes to 
the production of caries; and this it may do without this acid 
being the rnimediate cause of the decay. A tooth may be frac- 
tured, or its enamel be removed, by mechanical means; and as the 
dentine is thus exposed, the tooth is more liable to caries than 
before the exposure. But no one supposes that the mechanical 
action which exposes the dentine is the immediate cause of the 



DENTAL CARIES. 479 

caries. The dentine would remain sound and healtlij did not 
some chemical agent attack it. In like manner, in the administra- 
tion of acids as food or medicine, the teeth may be so corroded as 
to expose the dentine, and render it as liable to the action of the 
carious agent as in the former case ; or if the dentine is not 
exposed, the enamel may be roughened, either mechanically or 
chemically, so as to afford a lodgment for organic matter, which, by 
decomposition, may generate one of the acids immediately con- 
cerned in the production of caries. On this principle, acid medi- 
cines and acid foods may indirectly, but not immediately, cause 
caries. The same remarks will apply to acids brought in contact 
with the teeth by eructation or vomiting. 

If this view is correct, the investigation of the subject of dental 
caries is brought within a narrower compass than many suppose. 
The first step is to inquire what acids, in health and disease, are 
liable to be secreted or excreted, so as to be brought regularly in 
contact with the teeth. The second is to ascertain what acids are 
liable to be formed within the mouth by fermentation or otherwise. 
And the third is to discover what ones of all these are capable of 
producing the phenomena c^f dental caries. There is but little room 
to doubt that, at least, each of the first three varieties is the result 
of a specific agent. 

To properly understand any chemical action to which the teeth 
are subject, it is necessary to bear in mind their texture and com- 
position, and to consider the chemical properties of at least their 
principal constituents. It must also be remembered that the teeth 
are endowed with vitality. As dental caries — the most common 
disease of the human race — is now universally conceded to be the 
result of chemical action, the importance of this subject is at once 
manifest. The time is not far distant when in every case of recent 
caries, the enlightened practitioner will be able, by the character 
of the decay and the habits and constitution of the patient, to 
detect and identify the agent or agents producing the disease. 
Any practice short of this knowledge must be, at least to some ex- 
tent, guesswork, and is, although the best we can now do, empirical 
practice. 

The fact that an active alkaline base is the principal inorganic 



480 APPENDIX. 

ingredient of the teeth, would indicate clearly that their great 
danger lies in the presence of acids ; and all experience demon- 
strates the truth of this inference. This danger is also greater 
from the fact that the principal salt of this base, present in the 
tooth-substance, combines with several acids without undergoing 
decomposition. 

It is evident that the acids do not all act alike on the teeth. 
Indeed, some exert no influence whatever on them, while others 
act with great energy on each and all of their constituents. It 
would be an endless task to consider all the substances which are 
capable of exerting an injurious chemical influence on the teeth; 
and perhaps it would be as unprofitable as endless. All that is 
now aimed at is an accurate account of the various substances which 
ordinarily act chemically on the teeth — which produce caries and 
'' chemical abrasion." 

Without further preface, we will proceed to notice some of the 
the chemical agents alluded to. 

Nitric ^c?'c?.— This acid is composed of five equivalents of oxy- 
gen united with one of nitrogen. Its symbol is therefore, NO^. 
It acts with great energy on all the constituents of the tooth. Its 
great energy of action depends on a variety of circumstances. As 
an acid, it unites energetically with bases, and will, therefore, take 
the lime and kindred bases from the weaker acids. From its ready 
decomposition, it aff'ords oxygen, in its nascent condition, for the 
destruction of oxydizable substances. Its action on the tooth may 
be thus briefly described : it dissolves the phosphate of lime, de- 
composes the carbonate, setting the carbonic acid free, and forming 
nitrate of lime, and destroys the organic portion, producing a 
highly-softened state of the carious matter. In fact, it is a promi- 
nent, if not the principal, agent in the production of the " white 
decay." 

But the question naturally arises. Is an agent so destructive in 
its tendencies likely to come in contact with the teeth, and if so, 
under what circumstances ? The question is important, and the 
answer, perhaps, diflBcult. 

It is well known that this acid is frequently administered as a 
tonic; and it is a lamentable fact that far too little attention is paid 



DENTAL CARIES. 481 

to the prevention of its injurious effects on the teeth in such cases, 
but this will by no means account for the frequency with which it 
evidently injures the dental organs. A few thoughts in regard to 
its formation may throw some light on the subject. 

It is a singular fact that though nitrogen and oxygen manifest 
but little affinity for each other, yet they unite in various propor- 
tions, forming at least five well-known distinct compounds. It 
appears, however, from a variety of circumstances, that their ten- 
dency is to unite in the proportions which form nitric acid. The 
protoxyd is readily decomposed, and yields nitrogen, oxygen, and 
nifroue acid. The binoxyd, if brought in contact with the atmos- 
phere, takes from it two equivalents of oxygen, and also becomes 
nitrous add, or NO^. Hyponitrous acid, NO3, on admixture with 
water, is converted into nitric acid and binoxyd of nitrogen, thus : 
3N03=N05-1-2N02, in which case the latter will be converted into 
nitrous acid, which, in the presence of water, is converted into 
nitric acid and binoxyd of nitrogen. 

It follows from this that, if oxygen and nitrogen unite at all in 
the mouth, let the proportions be, at the first, what they will, nitric 
acid must be the ultimate result — as air and moisture, the only 
agents necessary in the transformation, are here always present. 

The reader will now think of the mucus, and particles of nitro- 
genous food lodged about the teeth undergoing decomposition, and 
yielding nitrogen to the oxygen of the atmosphere, or of the fluids 
of the mouth, and will conclude that all is explained. Well, per- 
haps it is. But let us consider. Nitrogen is emphatically a " con- 
servative" element, and manifests but little tendency to unite with 
anything, and especially with oxygen. It is probable, therefore, 
that these two elements unite indirectly. It should be borne in 
mind that organic nitrogenous bodies contain hydrogen and oxy- 
gen, as well as nitrogen. Consequently, by their decomposition, 
these elements are all liberated. The mutual affinities of hydrogen 
and nitrogen take precedence, and the result is the formation of 
ammonia, NH3. But ammonia exposed to the action of ox3'gen is 
always decomposed ; an oxyd of nitrogen is formed, and of course 
nitric acid is the result. 

With this view of the case, and from the fact that many persons 

FP 



482 APPENDIX. 

permit the buccal mucus as well as particles of nitrogenous food to 
remain around, upon, and between the teeth, till decomposition is 
effected, it is not surprising that the white variety of dental caries 
is so frequently found. 

Nitric acid is also sometimes formed in the mouth by the agency 
of galvanic action. When two metals are placed in the mouth in 
proximity to each other, and the fluids of the mouth are capable of 
acting on one of them, galvanic action is established. And if they 
are so situated that the mucus membrane forms a connecting con- 
ductor, by being in contact with both, especially if the metallic 
surfaces be considerable, a current is established sufficient to 
decompose any of the binary compounds contained in these fluids. 
The liberated nitrogen, hydrogen, and oxygen will result, as above, 
in the formation of ammonia, and then nitric acid. But galvanic 
action in the mouth is more likely to develop hydrochloric than 
nitric acid. This will be noticed again. 

Sulphuric Acid. — Sulphuric acid is composed of 16 parts of 
sulphur united with 24 of oxygen. Its symbol is, therefore SO3. 
In addition to those properties which characterize it as an acid, it 
is a powerful caustic poison, and promptly destroys the various 
tissues with which it comes in contact. Its chemical action on 
ordinary tissues depends principally on its affinity for water, but 
not altogether ; for it has the ability to coagulate and unite with 
albumen, and to dissolve fibrin. In common with other acids, it 
has a strong affinity for alkaline bases. 

With these properties in view, let us examine its action on the 
teeth. 

The affinity of this acid for water is so energetic that it seems 
even to force its elements to forsake favorite combinations, and to 
unite with each other, that it. may be gratified. For example, a 
cork in a bottle of sulphuric acid becomes dark-colored, and is 
really charred. Now a cork, like other wood, is mainly composed 
of carbon, hydrogen, and oxygen — the latter two being in the 
proper proportions to form water. Their affinity for each other, 
quickened by that of the acid for the result of their combination, 
causes them to forsake the carbon, unite with each other to form 
water, and then combine with the acid. The same phenomena 



DENTAL CARIES. 483 

occur when it acts on animal tissues ; for they are principally com- 
posed of the above-named elements, with the addition of nitrogen. 
Accordingly, " black spots are frequently observed in the stomachs 
of those who have swallowed the acid." Now, that its slow and 
prolonged action on the gelatinous portion of the tooth would 
result in its carbonization, is a conclusion justified both by infer- 
ence and experiment. But carbonized gelatin is " animal charcoal," 
the color of which is a prominent characteristic of " black decay," 

The phosphate of lime in the tooth, which is not the neutral, 
but a subphosphate, is not soluble in sulphuric acid ', nor is the 
acid capable of decomposing it, except in the presence of alcohol. 
It follows, then, that this acid does not break down the texture of 
the tooth to the extent that some others do, simply because it can- 
not unite with, or, under ordinary circumstances, decompose the 
principal earthy salt of which it is composed. And here we have 
a second characteristic of " black decay." 

It is now time to inquire whether at all, and if so, by what 
means, and under what circumstances, this acid is brought in con- 
tact with the dental organs. 

Sulphuric, lil^e nitric acid, is frequently administered as a med- 
icine, and generally with criminal negligence in respect to its 
action on the teeth. But we cannot regard this as the only or 
principal source of danger from this acid. If oxygen unites at all 
with sulphur, the tendency, under ordinary circumstances, is to 
the formation of sulphuric acid, as sulphurous acid in the presence 
of moisture is rapidly converted into the sulphuric. The whole 
question, then, is reduced to this, Is sulphur ordinarily present in 
the mouth, and liable there to become oxydized ? 

Albumen is a constituent of mucus, and is contained in many 
articles of food. Sulphur, if not a constituent of, is always united 
with albumen. Its ordinary presence in the mouth is therefore 
easily explained. Sulphur and oxygen unite directly, under 
various circumstances, as in the combustion of sulphur ; but it is 
probable that the union here is effected by indirect means. Hy- 
drosulphic acid, or sulphuretted hydrogen, is one of the results of 
the putrefactive decomposition of albuminous substances. The 
breaths of our patients often bear ample testimony to its presence 



484 APPENDIX. 

in the mouth. Now, the oxygen of the atmosphere rapidly decom- 
poses this acid by taking its hydrogen to form water. The sulphur 
is therefore set free, and being in its nascent state, its affinities are 
increased in energy, and it also unites with oxygen, forming sul- 
phurous acid, SOg, which in the presence of the water of the saliva 
is rapidly converted into sulphuric acid, or SO3. 

The quantity of sulphur present in the mouth at any one time 
is very minute ; and a great proportion of this is exhaled by the 
breath before it has time to undergo decomposition. And sul- 
phuric acid, as already noticed, has a weaker affinity for the con- 
stituents of the tooth than some others. Hence " black decay" is 
not so frequently met with as some other varieties. And as from 
the nature of the chemical action the texture of the tooth is not so 
entirely broken up, the carbonized portion protects the parts 
beneath it. This variety of decay therefore progresses less rapidly 
than others. 

Hydrochloric Acid. — This acid is also called chloro-hydric and 
muriatic acid. It is composed of 35 parts of chlorine, united with 
1 of hydrogen. Its symbol is HCl. Though its elements manifest 
a strong affinity for each other, yet it is very readily decomposed ] 
and many of its chemical manifestations result from the action of 
one or both of its liberated elements. It is on this principle the acid 
attacks metals — being decomposed, the chlorine unites with the metal 
to form a chloride, and the hydrogen escapes with effervescence. 

This acid, like those previously considered, is a caustic poison. 
Its escharotic power depends mainly on its affinity for water, 
which is very active, and on its ability to coagulate albumen. Its 
chemical action is generally inferior to that of the two acids just 
considered. It unites with bases, forming a class of salts called 
hydrochlorates ; and sometimes it combines with a salt without 
decomposing it, or being itself decomposed. When concentrated, 
it dissolves animal tissues, but is in this respect far inferior to 
nitric acid. When much diluted and mixed with dried mucous 
membrane, it dissolves coagulated albumen, fibrin, etc., performing 
to all appearance an artificial digestion. 

A careful observation of these properties will enable us to under- 
stand the action of this acid on the tooth. 



DEx\TAL CARIES. 485 

The carbonate of lime and the acid are mutually decomposed. 
The results are chloride of calcium, water, and carbonic acid. The 
decomposition may be represented by the following equation : 
CaO,C02-f-HCl=CaCl + HO+CO,. 

The carbonic acid of course escapes as a gas, and the chloride, 
being very soluble, is dissolved in the saliva, and thus removed from 
the tooth. 

The phosphate of lime (bone phosphate), though not decom- 
posed by, is highly soluble in hydrochloric acid. It is dissolved, 
and is thus removed from the organic portion of the tooth. 

We have seen that this acid, unless highly concentrated, is not 
capable of dissolving the animal portion of the tooth. As this con- 
centration is not likely to take place in the mouth, it follows that, 
when hydrochloric acid is the cause of dental caries, the earthy 
portion is dissolved and removed, while the animal portion princi- 
pally remains in the carious cavity. And here we have the promi- 
nent characteristics of a third variety of decay. 

I have not taken into the account any of the earthy salts con- 
tained in the tooth, but the phosphate and carbonate of lime. 
They are present in such small quantities that they exert but little 
influence on any of the chemical actions which we have considered. 

Hydrochloric acid is also administered as a medicine ; and the 
remarks made on the preceding acids apply equally here. This 
acid is an ingredient of the gastric fluid, and is often present in 
abnormal quantities in the stomach, from which it is thrown into 
the mouth by eructation and vomiting. But we cannot thus 
account satisfactorily for the frequency with which the dental 
organs are evidently injured by this acid. 

Though in its normal state the saliva is alkaline, yet in a variety 
of abnormal conditions it contains one or more free acids ; and the 
hydrochloric is one of those most frequently present. It often 
originates no doubt in the decomposition of the soluble chlorides 
contained in the saliva and mucus. When the chlorine of these is 
liberated, it takes hydrogen from the water of the saliva, and this 
acid is a result of the union. 

But sometimes hydrochloric acid is directly furnished by the 
salivary glands, either as a secretion or an excretion. The system 



486 APPENDIX. 

may contain just its normal quantity of chlorine, but if there be a 
deficiency of sodium or potassium, the relative excess of chlorine is 
converted into hydrochloric acid. In this case the acid is secreted. 
Or the quantity of potassium, and sodium may be normal, with an 
excess of chlorine. The excess will unite as before with hydrogen, 
and the acid will be excreted. At all events, this acid is usually 
found in the mouth when the mucous membrane is inflamed, as 
well as in patients who indulge in the excessive use of salted 
meats. 

Galvanic currents in the mouth always result in the formation of 
this acid. The chlorides of sodium and potassium, present in 
normal mucus and saliva, are decomposed, and their chlorine unites 
with hydrogen derived from the water of the saliva. It is on this 
principle that we frequently find a decayed surface around a gold 
filling, which is in close proximity with one of a different metal, or 
with a silver plate or clasp. In such decays, the animal portion 
usually remains, while the earthy portion is removed, just as would 
be expected from the prolonged action of dilute hydrochloric acid. 

In these observations we have endeavored to set forth the results 
of the ordinary uninterrupted action of these acids on the teeth ; 
and we have seen that they are capable of producing the three 
varieties of decay usually described, though we by no means main- 
tain that they are the only agents capable of causing these results. 
Their actions, and consequently the characteristics of decay pro- 
duced by them, are doubtless much modified by circumstances. 
One of them may be the destructive agent in the commencement 
of the caries, and, in process of time, another may be developed, 
and exert its specific influence on the same cavity. Then the phe- 
nomena would of course be complex. Again, it should be remem- 
bered that a strong afiinity for water is a property common to all 
of them. It is possible therefore that carbonization or blackening, 
may result from the action of any of them, yet it is by no means 
probable, at least with nitric acid. 



DR. palmer's plugging INSTRUMENTS. 48' 



SECTION B.— DR. CORYDOX PALMER'S PLUGGING 
INSTRUMENTS. 

In the following pages are given a description, and the mode of 
using Dr Palmer's very complete set of plugging instruments. 

They are illustrated in this volume, page 136 (Fig. 55). The 
manner of using them is so explicitly given in these pages, that no 
one of experience in the use of instruments can fail to apply them 
as intended. 

They constitute, altogether, the most perfect set of plugging in- 
struments ever devised. They niore nearly meet every case, that 
may be presented, than anything heretofore used. 

Several instruments, accessory to the set, are here described. 
that are not illustrated in this volume ; they are all. however, very 
valuable, and exactly adapted to the purpose for which they were 
designed. T. 

In the designing of these instruments for the profession, it has 
been my aim to perfect a set that shall enable the operator to reach 
with mallet force any case that may be presented. 

A course of practical experiments dating back to the introduc- 
tion of the use of the mallet, has brought me to the present designs. 

In conducting the course, my object has been — First, to get the 
best adaptations ; second, to have as few curves as possible ; and 
third, the least number of instruments that will do all the work ; and 
lastly, to have the size and length of each instrument proportionate 
to its use. 

There is no one thing that we owe so much to our fellow-prac- 
titioners as to give to each credit for what he does toward the 
improvement and elevation of our science. 

For my own part, I do not claim entire originality in the forms 
of my instruments. For principles, I am indebted to our worthy 
friend, William H. Atkinson, and for valuable interchanges to 
Charles R. Butler. 

All instruments for mallet forces can be but modifications of the 
foot. My efforts have been to produce a mallet set, to be used in 



488 APPENDIX. 

their numerical order, that shall indicate a systematic course of 
operating. 

The plugging set consists of thirty-five pieces. Up to No. 16, 
they pertain to the incisors ; and I would especially recommend 
that they be used only upon these teeth. The tendency will be to 
use them in every case ; but it is too much risk for such fine 
points. 

Do not pick up the gold upon the point of the instrument and 
hold it in the lamp, as it will quickly destroy the temper. 

From No. 17 to 30, the instruments pertain to the bicuspids 
and molars. 

In order to describe the instruments, we must suppose a case : 

Left superior central, anterior approximal surface, cavity, pre- 
pared with fine retaining pits at each angle of the cervical wall. 

The first three in the order of their arrangement are cutting in- 
struments, and designated by dots to distinguish them from the 
pluggers. Ihe first one is a fine elastic drill, for retaining pits. 
The second is a fine scoop for clearing the pit. The third is a 
curved side-cut, for clearing the last par';icles from the cavity 
proper. These three instruments are indispensable to the last pre- 
paration of the cavity, and must necessarily be clas-'ified with the 
pluggers for the present; but it is my intention that they shall 
comprise the last and higher numbers of a systematic-set of cutting 
instruments to be brought forward in due course of time. 

The two instruments No. 0, are holders for keeping the gold in 
position until it can be tacked fast. The one with a guard in the 
centre is to be used when no assistant is at hand ; and when held 
between the first and second fingers, the guard is designed to pre- 
vent the fingers from slipping down. The rounded top will be use- 
ful upon which at times to rest the forefinger of the left hand at 
the first joint, and help to regain position of the fingers. 

Holders are important instruments, not familiar to all. I would 
draw attention to their use. I feel a particular pride in this one 
new design. It is purposely short, in order to bring it more easily 
under control ] and having the guard, will enable the operator to 
hold it and the plugger in one hand, at the same time. 

The manner of retaining is to place the holder between the first 



DR. palmer's plugging INSTRUMENTS. 489 

aud second fingers of the left band, letting them rest upon the 
guard, and place the plugger between the thumb and forefinger, 
letting the points of the instrument cross in the cavity. 

Ko. 0, without a guard, is to be used when the help of an assis- 
tant is at hand, and taken up at choice. 

The two holders and the plugger may form at times a useful 
trio. Used without an assistant, the three can be held in position 
by the left hand, and the stroke given by the right ; or, with assist- 
ant help, the two holders in the left and the plugger in the right 
hand. 

The manner of holding th'^ three in one hand is to place the two 
holders in position, as above described, and then add the plugger 
between the thumb and forefinger, in front of the holders, letting 
the points come in position. With assistant help, the two holders 
are held in position as abovf , and the plugger held in the right 
hand. 

I do not wish to be understood that the holder is to be used 
throughout an entire operation ; but that in the starting of a filling, 
it is indispensable, and at other times useful, as may be indicated. 

No. 1, Fit Point, is to introduce the first pieces of gold into the 
retaining pits, and fill all minute cavities upon the labial surfaces, 
where ease of access and direct force can be had. 

No 2, Small Foot, is to introduce the first pieces of gold after 
the pits are filled, and is to be applied until the gold is made to 
extend from one pit to the other and firmly attached. 

No. 3, Foot, is to add a portion after No. 2, and do the burthen 
of the work in filling the cavity even with the edges of the wall. 

No. 4, Foot, is to be used to lay the gold along the cervical wall, 
by letting the heel pass into the cavity, and the point project 
obliquely beyond the edge of the wall, so as to carry the gold hard 
upon and perfectly along its whole line. 

N^o. 5, Curved Foot, is to apply upon the inner surface of the 
labial wall, by opening the mouth and applying it direct from the 
lingual surface. Its curved point will admit of its being brought 
in contact with the w\^ll with less danger of fracture than the plane 
foot. It also has a working point, which may be applied with 
directing force with advantage. 



490 APPENDIX. 

JVo. 6, Double Serrated Pit Pointy is to carry the gold into the 
apex of the cavity, toward the cutting edge of the tooth. This 
instrument deserves especial notice. It enables the operator to 
carry the gold with mallet force into this part of the cavity with 
ease and certainty. It must be used with careful directing force ^ 
and can be applied either from the labial or lingual surfice. 

No. 7, Slot Plugger, applies in filling the slot, extending from 
the apex of the cavity to and along the line of the cutting edge, 
or wherever slots occur upon the incisors. 

No. 8, Lingual Modeler^ applies in modeling up the lingual 
ridges of the incisors. Its form enables the operator to hold the 
point to or fi'om him, without danger of impigning upon the ad- 
joining tooth. By opening the mouth, direct force can be given. 
It will be observed that this and several of the other instruments 
are sloped forward in the handle, in order to favor their introduc- 
tion from the lingual surface. 

No. 9, Lingual Mallet Burnisher., applies in the last condensing 
of the gold, along the lingual edges of the cavity. Held at an 
angle bringing it to bear upon one of its sloping faces, it can be 
made to glide along, or bringing the point more to bear will follow 
minute lines, as may be desired. 

No. 10, Curved Cervical 3Iodeler, applies in modeling the gold 
at the cervical wall of both the incisors and bicuspids; is indispen- 
sable for condensing the anterior and posterior surfaces of bicuspid 
fillings. It will be found to reach these surfaces most admirably. 
By applying it as the operation progresses, the approximal surfaces 
may be modeled into form. 

No. 11, Curved Approximal Modeler, applies upon the approx- 
imal surface of the gold, after the cavity is filled even with the 
edges of the walls, and does all the remainder of the modeling of 
this part of the filling. The gold is to be laid on in flat pieces, and 
the instrument applied, both from the labial and lingual surfaces. 
Its curve enables the operator to pass it through so far between the 
teeth as to easily reach all parts of the approximal surface. This 
instrument forms a marked feature in the set, and becomes a great 
favorite. 

No. 12, Curved Crown Modeler. This instrument applies upon 



DR. palmer's plugging INSTRUMENTS. 491 

the cutting edges of the incisors and the elongation of their crowns, 
and upon all the teeth where direct force is required upon a flat 
surface. 

Xo 13, Curved Cusj) Modeler. In the operation of elongating 
the crowns of the incisors, the labial and lingual surfaces of the 
gold must be condensed, as the operation progresses. Direct force 
is not admissible, and this instrument, held -it an angle, meets the 
case. It is also designed to model cusps and fissures. 

^Vo. 14. Curved 3Iodel Sejjcwator, applies with mallet force in 
effecting a separation between approximal fillings in the incisors, 
and can be introduced from the labial or lingual surfaces, as the 
case may require. 

yh. 15, Side Curved Hand Separator. Useful in effecting a 
separation of the fillings, same as Xo. 14. 

Xo. 16, Curved Hand Burnisher^ for the last condensing and 
finish of the filling in the incisors. 

Xos. 17 and 18. Foot Instruments, are the same size upon their 
working faces as Nos. 2, and 3, and are to take their place upon 
the bicuspids and molars. Being designed to do the burthen of 
the work, they are made stouter, and with less angle of face, and 
less inner curve. 

Xo. 19, Foot^ is designed to lay the gold upon the cervical walls 
of the bicuspids and molars, by passing the heel into the cavity, 
and letting the point project beyond the edge of the cervical wall. 
Same as the use of No. 4. 

Xo. 20, Curved Foot, applies upon the thin ciu'ved buccal and 
lingual walls of the bicuspids and molars. 

Xo. 21, Slot Plug gers. used wherever slots occur upon the bicus- 
pids and molars. 

Xo. 22, Double-curved Holder, for the bicuspids and molars, and 
wherever a curved holder is required. 

Xo. 23. Double-curved Root Plugger.^ used with directing force 
in the palatal roots of the superior molars, and in all cases where 
large deep root cavities occur. It is the first of a class of eight 
instruments, purposely designed of a larger size than the previous 
numbers, in order to enable the operator at times to grasp the 
instrument firmly in the whole hand, and give directing force. 



492 APPENDIX. 

JVo. 24, Double-curved Croze-pointed Plugger^ applies in the 
deep angles of the posterior cavities of the inferior bicuspids and 
molars. Used with firm directing force. 

No. 25, Curved Molar Foot, has a working point, and is 
designed to introduce all the gold into the inferior central crown 
cavities of the molars. It applies with the use of the holder, by 
first securing the gold in the most deep, distal part of the cavity, 
and then working forward, extending the gold along the sides of the 
cavity, until the centre is passed, and then turning the point of the 
instrument and working backward until the walls of the cavity are 
entirely lined up ; then commence and bring up the centre of the 
filling to finish. This instrument is one of the most universally- 
acting and rapid-working points with which I am acquainted. It 
admits of being turned to and from the operator, and works across 
the mouth with great advantage. The position for the operator 
for the right inferior molar is back of and above the patient. For 
the left, if the operator is skilled in the use of the left hand, he 
need not change positions; but if change is required, stand at the 
left side and hold the instrument with firm directing force. 

JVos. 26 and 27, Eight and Left Treble-curved Bicuspid Plug- 
gers, are designed to introduce the gold into the posterior cavities 
of the inferior bicuspids and molars. The opinion has largely pre- 
vailed that direct mallet force could not be brought to bear upon 
this class of cavities ; but these instruments held in position, will 
give direct forward force, and can be worked across the mouth with 
great satisfaction. They also apply upon the superior bicuspids 
and molars equally well. 

Nos. 28 and 29, Right and Left Treble-curved Molar Modelers^ 
apply at the posterior cervical walls of the inferior bicuspids and 
molars, and serve to model up all the posterior surface of the 
fillings, enabling the operator to give most direct forward force. 
They reach a point that no other instruments will. Posterior lin- 
gual cusps can be reached with these instruments, and condensed 
upon their posterior and lingual angles, — a point that has been 
hard to reach. They also work across the mouth with great advan- 
tage, and can be applied to the superior bicuspids and molars as 
well. For applying the instrument to the right inferior molar. 



DR. palmer's plugging ixstruments. 493 

stand at the back of and above the patient, holding the instrument 
firmly in the whole hand, letting the thumb rest upon the shaft of 
the instrument, and next the cheek, and give tense directing force. 
For the left, stand upon the left side, grasping the instrument 
firmly with the whole hand, letting the fingers go next the cheek, 
and the thumb firm against the shaft, and give tense directing force. 

Xo. 30. Modeling Mallet Burnisher, has a combination of work- 
ing faces. Held at an angle upon one of its sloping faces, it can be 
made to glide along, and lay additional pieces of gold, if desired; 
or, turned more upon its point, will follow fine lines in the modeling 
of cusps and fissures. It will reach the posterior surfaces of the 
bicuspids and molars, and can be used for the last hand bm-nishing 
of fillings, if desired. Used with the mallet, must be grasped 
firmly in the whole hand, and given directing force. 

A word or two in reference to the finish. The instruments are 
purposely finished bright and polished throughout; because in a 
long course of careful practical experiments. I have found that 
finished in this way they keep better, and are more pleasing to the 
eye. After the brilliancy of the first finish is worn off, they will 
assume a certain dull, silvery surface, which makes them pleasant 
to hold, and they are always clean and presentable. 

The Cases are made from a new design of my own, suited to 
practice. 

They contain the plugging instruments, four pieces of forceps, a 
foil carrier, and dressing needle ; all of which are new, and especi- 
ally designed and adapted to the mouth by myself. 

Nos. 1 and No. 2 are punches for the rubber dam, and are so 
formed that they can be applied to put in new holes after the dam 
is adjusted, and thus enable the operator to extend the dam with- 
out the necessity of removing it from the mouth — a most desirable 
feature in its use. 

The Wedge Cutter is so formed and curved that it can be made 
to reach any point desired, enabling the operator to cut off a wedge 
far back in the mouth, or nip a point along the lingual surfaces of 
the teeth. 

The Wedge Forceps is an entirely new instrument, in size and 
form, pleasant to the hand and eye. Its curve enables the operator 



494 APPENDIX. 

to pass it far back in the moutli, to reach any point desired, and 
insert or withdraw a wedge, pull off a dipt ligature, or hold a piece 
of wood for porte polish, to apply upon the lingual surfaces, par- 
ticularly the inferior incisors. Must not be used for handling 
engine bits. 

The Foil Carrier is to be used for picking up the gold, holding 
it in the flame of the spirit lamp, and carrying it to the mouth. 
May be used also for introducing and removing dressings. Must 
be held between the thumb and forefinger, letting the top of the 
instrument pass over the back of the hand, and not placing the 
hand on the top of the instrument. The points are the most 
advantageously curved for its application to all parts of the mouth. 
This foil carrier is designed to be useful in a certain mode of prac- 
tice which I wish to recommend, and that is : during the operation 
of filling, not to lay down the foil carrier, but place it between the 
lips. In this way it is always ready, and no time is lost in hunting 
for it. I must not forget to caution against the danger of letting 
it fall in the face of the patient, and hope that all are thoughtful 
enough to be upon their guard in that respect. I dwell a little 
upon this instrument because it is one of the most important and 
first looked-for when we are ready to fill. It is not intended to be 
used as a plugger, and is made purposely light, and not with too 
stiff a spring, so that it can be held as above described, without an 
unpleasant strain upon the lips, and yet tempered and stiff enough 
through the body and points not to bend when used to insert or 
remove, a dressing. 

Dressing Needle. — Although this instrument has its more ex- 
tended range of usefulness, it is so inseparable from the operation 
of filling, that I consider the case would be incomplete without it. 

In the last preparation of a cavity, particularly where there are 
sensitive surfaces, it is desirable to give a dressing before introducing 
a filling. This instrument is the one best suited to the purpose. 

In case of dressing over exposed nerves, to allay pain, the 
rounded top will be useful to fix the cotton smoothly in position. 

In conclusion, let me say, that the instruments are designed to be 
graceful in form, artistic in finish, proportionate in size and length 
— each one having its particular use — together forming one syste- 
matic whole. 



MALLETS. 495 



SECTION C— MALLETS. 

The Electro-Magnetic Mallet. — Electro-magnetism has, 
within the last three or four years, been applied and used as a 
motive power for the automatic plugger. 

The plugging instrument operated by this force, though not in 
general use (and perhaps never will be), yet by some it is prized 
very highly, and used with great efficiency. 

To those unacquainted with electric force, and the appliances 
through which to make it available, this instrument will appear 
complicated and difficult to keep in proper condition, but to those 
familiar with it, it is easily controlled and manaiicd. 

The following extracts from a paper on the electro-magnetic 
mallet, by Dr. Louis Jack, is so directly to the point that we can 
hardly do better than present them here. 

He says, " The first attempt to take advantage of electro-mag- 
netism for this purpose, it would appear, must be credited to Mr. 
G. F. Grreen, who first produced, according to his own statements, 
an instrument in which he made use of the power which a heliacal 
coil has to draw within it towards its middle a piece of iron, sus- 
pended, or temporarily held at its either end. 

" At each influx of the electrical current the suspended iron 
would fly to the centre with quickness, to be stopped by the plugger 
end, arranged to meet it at that point ; at this moment the current 
was shut off, when the mallet would fly back, under the force of a 
spring, only to return again by the recurrent opening of the 
circuit. 

" The experiments with this class of electric pluggers have 
proven unsucessful." 

Mr. Green made other experiments which were equally unsuc- 
cessful. 

Dr. Jack further remarks : — " Entirely independent of any 
knowledge of what Mr. Greene had been doing in this direction, 
Dr. Bonwill, after watching the working of the armature in the 
magnetic telegraph, conceived, with true inventive talent, the idea 
of utilizing this arrangement, and with the necessary modifications 



496 APPENDIX. 

and adaptations to employ the force which impacts the style upon 
the paper, at the delivery of the same quick blows upon the plug- 
ging point. He therefore attached his armature by its middle upon 
a point at a distance relatively far from the electro-magnet, making 
the armature act as a mallet. Thus was secured a light and intense 
blow, and as the armature moved through a small distance, gained 
the additional quality of rapidity • a combination of qualities of 
the highest importance rendered his instrument practically efficient. 

" Dr. Bonwill has from time to time improved his first instru- 
ment, until we now have from his hands one which has proven 
satisfactory in most respects. To him, therefore, we are indebted 
for the first useful electro-magnetic mallet." 

After Dr. Bonwill had arrived at a point in the construction of 
this instrument beyond which he concluded not to go, Dr. Jack 
made some modifications of the instrument, the purport of which 
may be inferred from the following extracts : 

" The objects of this invention are to render the movements 
simpler and more direct than has heretofore been done, with the 
ends in view to produce a sharp and decided impact ; to lessen the 
sounds of the movement at both the time of the impact and recoil, 
and to produce a lighter, cheaper, more convenient and agreeable 
instrument. 

" The principal feature of this invention consists in the form 
given to the electro-magnet. The core is made the segment of a 
cylinder, so that when the helices are formed and placed together, 
they produce a more or less cylindrical body, leaving between them, 
at the central part, a circular aperture for the reception of a small 
cylinder. 

" This cylinder receives a plugger, which imparts the force 
of the armature upon the plugger, and at the same time permits 
freedom of movement and gives direction to the armature. 

" There are other improvements depending upon this one, and 
connected therewith, viz. : 

" The form of the armature and its connected parts. 

" The form and arrangement of the circuit closer, 

" The form and arrangement of the interrupter. 

" The device employed to deaden the recoil. 



MALLETS. 497 

" The means of securing the adjustments of the instruments. . . . 

" The best results, and the least discomfort of the patient are 
secured by careful attention to the adjustments. 

" It should be noticed in this connection that the greatest 
economy will be found in having the batteries in clean condition, 
replenished to good strength, and the zinc plates kept freely amal- 
gamated." 

In a paper on the electro-magnetic mallet, by Dr. E. T. Darby, 
July, 1875, in speaking of the advantages which the electric mallet 
possesses over all other instruments intended for the purpose of 
consolidating gold in the operation of filling teeth, he says : " It is 
purely automatic in its action. 

'' Its power or force is entirely distinct from anything physical 
or individual, except the will of the operator, and the touch of his 
educated finger. 

" No more physical force is required to manage it than would 
guide a pen or hold a pencil. 

" The dentist may stand, or sit in his chair, hour after hour, and 
fell no greater fatigue than would naturally result from restrained 
position, or concentrated thought. 

" Nor is it a labor-saving instrument only ; it is a time-saving 
invention also. 

" The length of time required to thoroughly pack the gold in 
most cavities is lessened at least one-half by the aid of the electric 
mallet. 

" Nor is it a time-saving instrument only, it is a pain-saving ap- 
pliance as well. 

" The blow produced by the electric mallet is sharp and quick, 
and does not jar the tooth like the hand mallet, or some other 
automatics. 

" The operator must be skilled in its use, otherwise he will fail 
to accomplish the best results." 

The paragraphs above quoted from the two papers referred to on 
the electric mallet, indicate about an average estimate entertained 
by those who have become thoroughly familiar with its use. 

The following illustration shows the present improved form of 
the instrument. 




SMAnr sc. N. Y\ 



Description of Electro-magnetic Mallet of Dr. Bonwill. — No.- 1, 
f size. E, the horse shoe magnet. M, the brass frame fixed 
firmly to magnet at the top, and holding the arm 0, at L, on two 
pivoted screws, R, hard rubber handle, with tool P running 
through it and extending as far to the right under the hammer as 
A. K, slide key, upon which right index finger rests for making 
the circuit, and causing the blows in rapid succession by simply 
pushing slide or key forward. F, the ring through which right 
index finger passes and supports the mallet and prevents falling. 
Thumb rests on tool just below K, and revolves tool in any direc- 
tion. J, an eccentric screw head to regulate the slide K, to make 
it of very delicate touch. L, posts into which the flexible wires 
from battery go. N, spiral spring inside for throwing the armature 
O back against the check screw head C, which head also opens or 
closes to control the distance the hammer travels. H, screw to 
regulate strength of spiral spring in N. D, B and A, the auto- 
matic brake, which controls the number of blows of hammer. B, 
screw head for raising or lowering to permit the tool to always keep 
the right distance to be struck by armature, or hammer. Makes 
500 to 3000 blows a minute. Weight, eight ounces, avoirdupois. 

Mallet No. 2. — This is exact size of magnets and the frame. It 
weighs but 6i ounces avoirdupois. 

H, horse shoe magnets, very compact. L, the armature without 
frame or hammer thereon. A, screw to regulate the spring of the 
circuit braker. B, posts for attaching flexible wire from battery. 
C, automatic brake, which is struck by point of spring F, and is 



MALLETS. 



499 



always pressing hard thereon. E, screw regulator of tool, permit- 
ting it to let head of tool project enough to move forward about 




E N 

one-fiftieth of an inch when struck by M on the end of brake 
C. Gr, handle of hard rubber. 

This is now as complete as can well be made. The first instru- 
ment weighed one pound. This last is all we could ask in size 
and weight, as well as shape. The handle and the hammer on 
the armature are not shown in the cut of this mallet, nor is the ring. 

They are both run by three cups of smallest size Bunsen Coke 
Battery ; it costs about 15 cents a week to charge them. These are 
the only practical electro-magnetic mallets now in use. As to 
saving of time, it has been claimed by the inventor that he has 
packed one-quarter ounce foil in one hour fifteen minutes. It will 
save three out of four hours, and nearly all the labor. 



Automatic Plugger for Engine. — This instrument is the 
invention of Dr. T. L. Buckingham, and, as the caption indicates, 
is operated by the dental engine. Those who have used the in- 
strument and are most familiar with it claim that it possesses every 
available quality for such an appliance. The blow is given by a 
spring, and is entirely under the control of the operator; it is 
regulated by a set screw on the head and a movable collar on the 
hand-piece. The latter can be moved at will during the operation 
of the instrument, regulating the stroke from the strongest required 



500 APPENDIX. 

to the lightest appreciable touch ; or the blows can be suspended 
altogether and the instrument used as a hand plugger, and that, 
too, without stopping the engine. 

The requirements of delicate operations needing special and pre- 
cise manipulation, are well met by the skillful use of this instrument. 

The bit holder is movable, and is drawn back after each blow 
by a small spiral spring attachment. 

The instrument as ordinarily used gives about eighteen hundred 
blows per minute, but the number can be greatly reduced by a 
simple change in the machinery, which can be effected in a few 
moments, and thus the blows reduced to less than one hundred 
per minute. 

The points used in this are such as are in common use with 
automatic mallets. 

A ring accompanies this instrument, which being attached to it 
will aid the operator in holding and directing it while operating. 
It is represented by the following cut (Fig. 128). 

Hyde's Pneumatic Plugger. — This instrument was devised 
and introduced to the profession about 1870. It consists of a 
small cast iron frame, to which is attached a small cylinder, which 
with its piston serves as an air pump ; this is operated by fly and 
drive wheels which are arranged in the frame and operated by the 
foot. 

To the cylinder is attached a rubber tube about seven feet in 
length ; to this is attached the hand piece, within which a plunger 
plays ; when in motion this communicates its impulse to the 
plugger. 

As the plugger in the cylinder is driven to and fro, the hammer 
in the hand piece responds, expending its force upon the socket 
piece that holds the plugging point. 

The blow is direct and elastic, as the piston or hammer is with- 
drawn the moment the blow is given. 

The rapidity of stroke, as well as the force, is completely under 
the control of the operator. 

This instrument, in the hands of those who have become familiar 
with it, is very efficient and easily operated. 




501 



502 APPENDIX. 

A modification of this instrument has been made, which consists 
of substituting a rubber ball, about three inches in diameter, for 
the frame, wheels and cylinder ; and the operation is eiFected by 
working the foot upon the ball. This certainly has the advantage 
of being much more simple. 



SECTION D.— MATRICES FOR PROXIMAL FILLINaS. 

To Dr. Louis Jack belongs the honor of devising and putting 
into practical form the matrices as aids in filling teeth. 

His description of these appliances, and the manner of using 
them, is so concise and complete, that we have, with his consent, 
transferred it almost wholly to these pages. By a careful study 
of the directions here given, almost any one of good manipulative 
ability will be able to use them with good results. T. 

" The first step, in case the teeth are in close contact, is to sepa- 
rate them, either by pressure, or, as in so extensive caries as is 
under consideration, by a parallel-sided file ; and from this slight 
separation rapidly and freely open by cutting down the enamel at 
the middle of the space, afterwards increasing somewhat freely 
with the chisel the inner portion of the opening. Another plan I 
sometimes pursue, where no fracture of the masticating plate has 
occurred, is to pass a small five-sided drill until it fails to meet 
with resistance, increasing by a larger drill ; and from these two 
half circles I cut in either direction with suitable chisels by care- 
fully splitting down the enamel, — first the masticating portion, — 
and continuing until a free space is secured on the inner side; then 
more carefully opening towards the buccal division, until a slight 
space is made at this point. The file may be used at this stage to 
further open the space, and in bringing the surfaces into proper 
shape and smoothness. When the cavities are so large as is as- 
sumed above, there will usually be found so much disorganization 
of the enamel as to render necessary so much cutting to procure a 



MATRICES FOR PROXIMAL FILLINGS. 503 

healthy surface as will open a space abundantly large for the sub- 
sequent work. If more is needed, it is secured by wedging; in 
any case a separation as large at the lower part as a No. 7 Froid 
file, and at the cervical part as a No. 3, is easily secured. The 
buccal space should be but slightly wedge-shaped, and somewhat 
smaller than the palatal, for reasons which will appear in the 
proper place. 

After removing the softer caries, the walls of the cavity are pre- 
pared for the reception of the filling; the overhanging masticating 
plate being first cut away in a circular form on a line with the 
bottom or pulp wall, so that by direct approach every part of the 
cavity is accessible to slightly curved or even straight instruments. 
This opens the whole cavity to view. The instrument best adapted 
for this purpose is the gouge-shaped chisel, which cuts with ex- 
ceeding keenness, and produces the form desired at this part. 
The removal of this portion of the enamel is an important and in- 
dispensable step in the improvement I am pursuing. It is prac- 
ticed by the better operators to a somewhat less degree, and is in 
many cases an advantage to the organ. No other argument to de- 
fend this course may be used than that in these fillings, so difl&cult 
of execution, everything subservient to better performance must 
be followed out which is not injurious to the strength and preser- 
vation of the organ. It will often prove true here, as elsewhere in 
surgery, that something must be taken to save the remainder. 

The cervical wall is now cut at a right angle to the proximal 
surface, taking care to remove from the surface of the tooth beneath 
the gum any half-decomposed enamel which may be present at this 
part. No retaining groove or pits are needed on this wall. 

The buccal and palatal walls are next smoothly cut, and on the 
side of each, where they have sufl&cient strength, a shallow, round- 
bottomed groove is made the whole length, and terminating at the 
very surface of the masticating plate of enamel. The outer retain- 
ing groove should be near the margin, to avoid any approach to the 
pulp ; the inner one should be nearer the bottom of the cavity, 
so that, in the subsequent cutting away of a portion of the palatal 
wall in the finishing process, the hold of the gold may not be 
obliterated. The instruments best adapted for this grooving are 



504 APPENDIX. 

made by filing a straight point quite round and small, then bending 
at a suitable angle, and shaping so as to have the edge at the inner 
side of the curve. Instruments of this form are better adapted for 
cutting the hard dentine and enamel than any others, for the 
reasons that they may be made harder than usual without danger 
of breakage ; they cut with more keenness, do not chatter, leave 
the surface without sharp lines, and in grooving each cut follows 
in the last with certainty. They are directly reverse in form to 
the hoes and excavators in general use. 

The pulp wall of the cavity is not altered in the form it presents 
after the removal of the caries. 

The next and very important step is to remove the sharp corners 
of the mouth of the cavity ; and at every part well polish it with 
pumice-stone ; this facilitates the passage of the gold over the sur- 
face and the perfect contact of the foil with every part. This 
polishing is rapidly done by rotating a piece of boxwood armed 
with pulverized pumice. 

Selection is now made of one of the appliances figured below, 

which are intended to give form to the outer surface of the filling, 

and are called matrices for this reason. These little afiairs are 

made of a variety of shapes, sizes, and thickness. They are formed 

of slightly wedge-shaped pieces of steel, and are, as 

the cut designates, hollowed out at their thicker edge, 



which depression terminates at the thinner edge. At 
the part of the depression designed to give shape to 
the buccal edge of the filling the cut is generally abrupt and deep ', 
at the inner portion it is more shallow and more inclined. It will 
be observed that the depression widens as it passes toward the 
thinner edge to follow the usual form of proximal cavities.* The 
lower and thin edge is rounded, to outline the curved margin of 
the cervical wall, and to eff"ect pressure upon either the gum or the 
appliances used to stop the escape of mucus and blood from this 
tissue. 

The plane parts of the face are file-cut or coarsely draw-filed. 
The reverse side, represented in Fig. 130, and which for conveni- 

* In Fig. 129 the boundary of the right end of the depression should be 
similar to the other end. 



MATRICES FOR PROXIMAL FILLINGS. 505 

ence of description is divided into three sections, is in most cases 

plane and smooth, excepting at the section 

c, which is file-cut. It is often necessary ^^* 

to have this side in two surfaces: one sec 

/.--.-f^ ^ -9 



^^^-—l 



tion, a, parallel with the plane parts of the 
face, and from this point inclining to a thin 

edge. A very desirable form is to have section c bent backwards 
to follow the incline of the proximate tooth beneath the gum. At 
each end a square-cut is made to fit the plier ends represented at 
Fig. 131. After being formed, they are protected from oxidation, 
heated to redness, plunged in the cold bath, and temper 
drawn to near blueness ; after polishing the depression, ^' 
they will be ready for use. Quite a number of pairs '^ |[\ 
are necessary to meet the ^ requirements of the difi"ering ' 

cases ) but for the ordinary-sized simple proximal cavities, a dozen 
pairs varying in width, in thickness, and in size of depression, are 
all that I have found necessary. Fig. 129 represents the largest 
size required, those in most use not being more than from one- 
half to two-thirds this width and thickness. The character of 
these modifications will depend somewhat upon the desired end, 
since either a flat, contour, or excessively convex surface may be 
produced at the pleasure of the operator, or to suit the needs of 
the individual operation, by varying the form and depth of the 
depression. It is also occasionally necessary to have a matrix of 
unusual form to meet special cases, where the space is extremely 
great, or where, from the fracture of the outer plate of enamel, a 
steel one will not remain in position ; for this purpose I have found 
hard boxwood to answer quite well. Silver also, in such cases, will 
occasionally be found useful. I sometimes take an impression of 
the immediate part to assist me in the fabrication of a suitable ap- 
pliance. I have also made double-faced ones, which are so formed 
as on one adjustment to allow both cavities to be filled. For isolated 
teeth having large posterior cavities, a ring of silver may be used, 
carrying out the same principle in forming the portion which 
bounds the cavity. I have used the same plan in buccal cavities. 

The selected matrix should, at the convex edge, be a little 
thinner than the space between the teeth at their closest part by 



506 APPENDIX. 

the gum ; it should pass ahove the edge of the cervical wall, and 
should conform at this part to the contour of the tooth ; the lower 
and thicker edge should reach nearly to the masticating surface, 
and this edge should not entirely fill the lower part of the space ; 
above all, the depression at every part of its border should extend 
slightly beyond the edge of the cavity. 

After having secured the cervical part of the case from the en- 
croachment of moisture — by means of the rubber dam, or, when 
this is not applicable, wedges of wood, little rings of india-rubber, the 
string dam, short pieces of waxed twine, of such size as to remain 
firmly in place when drawn between the teeth, the application of 
dilute chloride of zinc, etc., or a combination of two or more of these 
means — the matrix is taken up in the pliers (Fig. 131), and pushed 
upward until it presses upon the gum or the appliances, and until 
it impinges tightly between the teeth. It is now wedged firmly 
against the tooth to be operated upon with little boxwood wedges ; 
these secure it in place during the packing. It is well usually to 
insert two wedges, one from the buccal side between the teeth near 
the margin of the gums, and one from the palatine or lingual side 
nearer the masticating surface of the teeth than the margin of the 
gum ; thus the matrix will be firmly keyed to its proper position. 
When the matrix passes up to the proper point, the wedging towards 
the cavity throws the lower edge against and somewhat beneath the 
projecting swell of enamel of the neighboring tooth, which adds to 
the security. However tightly the matrix may fit between the 
teeth, it will not frequently retain its fixedness unless securely 
wedged. Boxwood answers for this purpose better than any sub- 
stance I have employed, for the reason that it is so hard as to be 
unyielding, and on this account also does not require to be more 
than pushed into the space. The wedges should be made to con- 
form in size and shape to the space they are intended to occupy, 
in order that they may the more firmly retain their position when 
inserted. Moistening them with a solution of gum sandarac or 
mastic adds much to their security in position after they are intro- 
duced. The pliers (Fig. 131) are vadapted to their introduction. 

In case the adjoining teeth are not in contact, it is always neces- 
sary to introduce a wedge between them, to give greater firmness 




MATRICES FOR PROXIMAL FILLINGS. 507 

to the teeth and less discomfort to the patient. In all large cavities 
I fix the matrix previous to introducing the napkins. Where the 
rubber dam is required, it precedes this appliance, which may aid 
in keeping the rubber in place. 

For the small cases, the drying is done first, the napkins applied, 
and a hard rope of bibulous paper is passed against the gum, fol- 
lowed by the matrix. Fig. 132 represents the appearance of the 
parts at this stage, except the wedges, which are 
not shown. When the cavity is now examined, 
it will be found to present an open mouth, formed 
by its curved lower edge of enamel, and by the 
boundary of the matrix, through which funnel- 
shaped opening every part of the space is easily 
seen and directly touched. The case is now ready for the recep- 
tion of gold. 

I use for the upper half or more of the filling, ribbons of 
Nos. 4, 5, or 6, of non-cohesive gold, not annealed. These ribbons 
are made of one-fourth to whole sheets of foil, depending on the 
size of the space, and then folded into blocks, varied in length by 
the requirements of the case. For the lower third I prefer rolled 
gold of No. 20 to 30, of the most adhesive character, and annealed. 
I also use for this part in many cases " Eureka gold filling," No. 
15, with the greatest advantage, taking up one or more of the 
shreds, and working them in wherever needed. The first block or 
mat is passed up toward the outer border, until it reaches the 
cervical wall, when the lower end is pushed into place, and fastened 
by pressure into the upper part of the retaining groove. The 
second piece is secured in the same manner in the inner or palatal 
groove ; a further piece is forced between the two, and directly 
against the cervical wall. When a sufficiency of gold is placed 
upon these parts to save the tooth from contact of the points, 
the gold is securely malleted against the walls at all points, pay- 
ing particular attention to the junction of the tooth with the 
matrix. In this way I proceed, successively introducing and 
malleting, until the cavity is two-thirds filled, not hastening further 
at any point, unless the assurance is reached that the gold is per 
fectly consolidated. At this point I commence and continue the 



508 APPENDIX. 

employment of heavy gold, the first pieces of which should be well 
fixed in the gold previously introduced at the parts over the re- 
taining grooves, and also worked well into the foundation. It is 
now a simple matter to fill up the remainder with quickness. 

In case there should happen to be an encroachment by moisture 
at near the close of the packing, the gold may be made smooth on 
the exposed surface, dried, and the latter part inserted, with all the 
characteristics of a separated filling. The form of the last third is 
such that, if inserted with dryness, no portion can escape. The 
matrix should now be removed. 

It will be found, if the selection and adjustment of the matrix 
has been correct, that very little filing and cutting down of the plug 
will be required, and, in case the packing has been carefully per- 
formed, that the gold will be solidly condensed at every part. It 
will also be noticed that, while the gold is solid, it will not have 
become hardened in temper on the proximal surface, but yields 
laterally under the burnisher, not unlike lead or tin. 

I must at this point call attention to the importance of the adap- 
tation of the filling material to the cervical wall, which it requires 
no words to show will be secured by this method. There can 
hardly be a question that the general failure of proximal fillings is 
due to one or both of two causes, — the imperfect preparation of the 
cavity, and the want of solidity and adaptation of the gold at this 
part. When the filling extends to the gum or beneath it, and the 
teeth are not permitted to come into apposition here, this portion 
of the tooth, when well protected, is least liable to decay ^ as this is 
not the place where caries usually commences. And when the fill- 
ing reaches to the cementum, the recurrence of caries is still less to 
be apprehended, since it is a clearly established, but apparently 
overlooked, principle that this structure is the least liable of the 
dental tissues to destruction. It will be noticed how seldom failures 
occur along the cervical edge of gutta-percha fillings, even when 
carelessly performed. These considerations have been forcing many 
to seek for better means of securing adaptation, solidity, and 
smoothness at this part. 

The instruments for introducing the filling are of simple forms 
and direct action, but they should be in fine condition,— that is, 




MATRICES FOR PROXIMAL FILLINGS. 509 

the points should be well serrated, and sharp. The only important 
modification needed are some pairs of mated plug-gers. formed as 
at Fig. 133, in which one side of the edge is considerably longer 
than the other, which longer side, in malletino;. is con- 
stantly kept against the matrix; this effects the greatest 
pressure upon the margins, and secures with positiveness 
the perfect fullness and the proper consolidation of the 
gold at these parts. Several sizes and varied curves of 
this point are required. 

The finishing of the case is not different from the usual 
course pursued. In my own practice I open still further 
the inner portion of the space, which is easily done with 
chisels and suitable files. The peculiar form of the 
depression in the matrix produces a space which is considerably 
greater on the inner side, and which may be increased at pleasure. 
In many cases, where the tendency to caries is very great, I chisel 
quite freely from the inner plates of enamel, doing this after both 
the adjoining fillings are inserted, cutting down both gold and 
enamel together, allowing the fillings to touch only at the promi- 
nent outer part. The result is then an imitation of the exceedingly 
oval bicu.spid, the immunity from decay of which ail must have 
seen examples. 

Fio;. 13-4 represents a transverse section of two 
cases at a point immediately above the grinding 
surface, which exhibits the outline of the form of 
the cavity and finished surfiice of the gold. 

In full confidence, founded on considerable trial, 
I claim that this method of filling large distal-proximal cavities 
overcomes several of the chief difficulties and deficiencies hitherto 
experienced, as well as enables greater facility of performance, and 
the security of excellent results." 




510 APPENDIX. 



SECTION E.— SALICYLIC ACID. 

This preparation, though but recently introduced, promises much 
as a therapeutic agent in dental practice. 

The following quotations from those who have given it attention 
and considerable investigation, will convey some idea of its uses and 
value. 

The following, from the Chemist and Druggist^ indicates much 
as to its properties and characteristics. T. 

The dominion of " elegant pharmacy " has been extended ] anti- 
septics and deodorisers may no longer boast of an exclusive privilege 
to be as disagreeable and abominable as they please ; an aristocratic 
first cousin to carbolic acid has entered into trade, and is rapidly 
proving to demonstration the superiority of " blue blood." The 
advent, commercially, of salicylic acid as a substitute for carbolic 
acid may well be regarded as a great stride for those who cultivate 
" elegance " as well as utility and efficacy, for the former substance 
appears to possess a degree of antiseptic power equal, if not supe- 
rior, to that of the latter ; and while carbolic acid possesses a dis- 
agreeable smell and other unwholesome properties, salicylic acid 
appears as a crystalline powder, nearly colorless, possessing a very- 
faint sweet taste, and almost without any injurious action on the 
health. 

Salicin is the well-known vegetable principle existing in various 
species of the willow, poplar, and other trees and plants. Salicylic 
acid is a derivative of salicin. 

The little that was known of the physiological and pathological 
effects of salicin sufficed, at least, to draw attention to those of its 
derivatives, and especially to salicylic acid, which has been the 
subject of occasional comment in the scientific journals for some 
years past. That it was peculiarly and powerfully effectual to sus- 
pend or entirely prevent fermentation and putrefaction has only 
quite lately been recognized by the Grermans, who soon found that 
its natural sources, as above alluded to, were quite inadequate to 
enable the manufacturer to produce it in the quantities and at the 



SALICYLIC ACID. 511 

price that tnight soon become almost a necessity. Kolbe, Pro- 
fessor of Chemistry at the University of Leipsic, took the matter 
up, and recognizing the fact that phenol or carbolic acid might be 
so split up as to produce, amocg other substances, salicylic acid, he 
devised a process for its manufacture which is now practically em- 
ployed at a chemical works at Dresden. 

Phenate of sodium is first prepared by double decomposition of 
phenol of soda, and well-dried carbonic anhydride is then passed 
through the dry powder at a temperature of 110 degrees to 250 
degrees C. The carbonic anhydride combines directly with the 
metallic derivative of phenol, and alkaline salts of acids of a higher 
series are formed ; among these salicylate of sodium is dissolved in 
water and treated with hydrochloric acid, which by double decom- 
position sets free salicylic acid in small crystals. These crystals 
are washed, dissolved in hot water, and by recrystallization obtained 
in the form of a crystalline powder of a light brown color. The 
Oermans attempt to bleach the product so obtained, and provide 
an article at a very high price which is sometimes quite white, but 
most of that in the market at a more moderate price is of a light 
cream color with a reddish tinge. Dr. Squibb thinks that the un- 
bleached salicylic acid is, probably, of sufficient purity for nearly 
all, if not all, the practical pui-poses to which the acid is applied, 
while expensive chemical processes have to be employed in order 
to remove the small amount of coloring matter, which more than 
doubles the cost of production. Common sense seems to show that 
the coloring matter present is not of a kind, nor present in suffi- 
cient quantity, to interfere with the efficacy of the unbleached pro- 
duct, while the high price required for the more or less bleached 
product would shut out from employment for most purposes, what- 
ever might be its powers. 

Dr. Squibb describes the bleached or unbleached acid as occur- 
ring in minute broken acicular crystals, which give it the appear- 
ance of a granulated powder, soft and smooth under the pestle or 
knife, but somewhat rough or resinous when rubbed between the 
fingers. This powder is odorless and nearly tasteless. It has, 
however, a sweetish and astringent after-taste, with slight acridity 
in the fauces, but none in the mouth ; and though tasteless, it leaves 



512 APPENDIX. 

a disposition or incliuation to expectorate, whicli continues for 
some time. 

Salicylic acid is very difficultly soluble in cold water, but easily 
dissolved by hot water, alcohol and ether. An aqueous solution 
containing from 0.2 to 0.4 per cent, of salicylic acid may be ob- 
tained by cooling a hot solution, when the excess crystallizes out. 
The acid is far more soluble in water containing a small portion 
of neutral salt. In Germany a solution is used for surgical pur- 
poses which contains one gramme of the acid dissolved in fifty 
grammes of water containing three grammes of sodium phosphate. 
Salicylic acid is decomposed into phenol and carbonic anhydride. 

Its compounds with the bases or salts seem difficult to make, but 
salicylate of zinc, a crystalline salt moderately soluble in water, 
and salicylate of quinine, amorphous, insoluble in water but soluble 
in alcohol, have already been prepared in Germany. 

Dr. Squibb very properly points out that it is in all probability 
a purely accidental, although a very curious, circumstance, that a 
substance of long and well-established character as an anti-ferment 
should offer a molecular constitution so well adapted to be broken 
up into a still more powerful anti-ferment, for there is no relation 
whatever, either in composition or chemical or physical properties, 
between carbolic acid and salicylic acid, except in their effects by 
similar or altogether different reactions. Accordingly, it must not 
be hastily assumed that in salicylic acid we have simply carbolic acid 
under a new name, but the compound must be experimentally 
tested, compared, and then judged on its merits. Numerous ex- 
periments reveal the fact that salicylic acid is a powerful antiseptic ; 
indeed, it is asserted to be far more powerful and effective in 
smaller quantities than any other antiseptic. Consequently its 
innocuous character, and the absence of odor and taste which 
characterize it, make it immeasurably superior to carbolic acid, 
which possesses qualities sufficient to restrict its application within 
very narrow limits. Other advantages which salicylic acid is said 
to possess beyond all other antiseptics are, first, that it may be 
used in quantities sufficient to be completely effectual for surgical 
purposes, and yet devoid of any irritating action on the living 
tissues, nor does it produce inflammation, nor any caustic or corro- 



SALICYLIC ACID. 518 

sive effect in any quantity. Although the very small quantities 
that are effectual are quite neutral, it is admitted that large quan- 
tities may be iiTitant or painful, but not beyond what may be de- 
scribed as a stimulant. Secondly, it is said to have power over 
processes of decomposition which are beyond the reach of all anti- 
septics or anti-ferments, since it entirely suspends the chemical 
vitality which causes the production of the volatile oils in mustard, 
and bitter almonds, the effect of diastase, etc. Thirdly, it has no 
poisonous effect in any reasonable quantity. 

Brewer's yeast does not effect a solution of glucose to which 
one-thousandth part of salicylic acid has been added. Mustard 
flour, which, when treated with a little tepid water, almost imme- 
diately develops a sharp odor of essence of mustard, remains quite 
inodorous if a small quantity of salicylic acid be added. The 
action of emulsin, the ferment contained in sweet or bitter almonds, 
or amygdalin, contained in bitter almonds only, whereby essence of 
bitter almonds is produced, is entirely prevented by salicylic acid. 
Fresh milk mixed with 0.04 per cent, of salicylic acid and allowed 
to stand at a temperature of 80° F. in an open vessel took thirty- 
six hours longer to curdle than the same quantity similarly exposed 
in a pure state. The neutral salts of salicylic acid do not, accord- 
ing to Kolbe, produce this effect, but only the free acid. Beer 
containing one-thousandth part of salicylic acid did not become 
sour when exposed to the air, neither did it exhibit any trace of 
that cryptogamic vegetation which appears on the surface of spoiled 
beer. Eggs which have been plunged in a solution of salicylic 
acid for one hour remained unaffected for three months. Fresh 
meat on which the acid had been sprinkled remained sweet fur 
several weeks. It prevents or arrests the souring of worts, washes 
and beers of the brewers, and the putrefictive changes which • are 
so troublesome to the glue manufacturers. Urine to which some 
salicylic had been added was, on the third day, still clear, and 
without ammouiacal odor. According to the results obtained by 
Professor Neugebouer, fermentation may be prevented by adding 
100 grammes of salicylic acid to 1000 litres of beer. The same 
author recommends the use of a very weak solution of salicylic acid 
to rinse out wine casks, and thus hinder the formation of mould. 



614 APPENDIX. 

Small quantities of salicylic acid would also^ in the estimation of 
Professor Neugebouer, if added to wine, prevent that after fermen- 
tation which is the principal cause of muddiness in wines, and 
perhaps check all the wine diseases produced by the growth of 
fungi. Professor Kolbe finds that a half a gramme of salicylic 
acid is sufficient to check the further progress of fermentation pro- 
duced by the action of 5 grammes of beer yeast on a solution of 120 
grammes of sugar in 1 litre of water. It has been suggested that 
such facts as these will indicate the quantities of salicylic acid to 
be used in the manufacture of fruit essences, champagnes, beer for 
exportation; and by way, perhaps, of reassurance to those who 
might object to be dosed continuously with a chemical of which 
we know so little as of salicylic acid, it is stated that Professor 
Kolbe could take without disturbing his digestion or general health 
from 1 to 1.25 grammes of salicylic acid per diem either in water' 
or spirit. Surely, however, an isolated experiment of this kind is 
not enough to establish the harmlessness of the substance so as to 
warrant its recommendation for general employment in the prepa^ 
ration of articles of food. 

Moreover Professor Kolbe proposes to use this substance for the 
prevention of putrefaction in water stored on board of ships, the 
object to be attained either by dissolving the salicylic acid in the 
water itself, in the maximum proportion of 1 to 20,000, or by 
covering the bung-holes of the water-casks with cotton impregnated 
with salicylic acid. Would the salicylic acid be quite harmless if 
used in the former way ? A suggestion which we should feel much 
less hesitation in adopting personally is that a capital dentrifice may 
be made by perfuming an alcoholic solution of salicylic acid with 
oil of wintergreen. Used in small quantities, mixed with luke- 
warm water, it acts as an efi'ectual preserver of the teeth -, or an excel- 
lent tooth-powder may be prepared with salicylic acid. A " sprink- 
ling-powder " for the feet has also been proposed, which acts without 
checking the perspiration. It should be composed of salicylic acid, 
talc, powdered soap, and starch. Besides removing odor, it com- 
municates an agreeable softness to the feet. 

The phosphate of sodium, with a solution of salicylic acid was 
employed by Professor Thiersch to promote the growth of skin over 



SALICYLIC ACID. 515 

granulated surfaces. Or salicylic acid used alone or mixed with 
starch was used upon contused or incised wounds, and in operations. 
with excellent general results, destroying the fetid odor of cancer- 
ous surfaces and pyaemic ulcerations. 

We cannot over-estimate the importance of that branch of ex- 
perimental inquiry which deals with such questions as the influence 
of agents like carbolic and salicylic acids on septic and zymotic 
poisoning. These investigations should be pushed to their farthest 
limit, even if not one in ten put forward by chemistry repay the 
labor of investigation, for it is certainly in this direction of research 
that medicine must look with greatest hope of success to control 
those abnormal vital processes which so far may be modified but 
not stopped. The phenols will always retain their importance 
among this class of agents, surpassing as they do all that have been 
tried before them. If salicylic acid should prove another step in 
advance, the gain will be great, more especially as indicating discov- 
eries which may enable us to weild an undreamed-of-power against 
the most fiightful and hitherto unconquerable ills of humanity. 

In an article wiitten under the title of salicylic acid, and for the 
Deutsche VierteljaTirsschrift zvr Zahnheilkunde, by Dr. Ostermann, 
of Brunswick, reference is made to the experiments of Professor 
Kolbe, and says that in consequence of the successful results of the 
use of salicylic acid in the hospital, he was led to investigate it in 
its application to dentistry. Dr. Ostermann first communicated the 
results of his observations at the annual meeting of the Central 
Society of Glerman Dentists. 

The following extract, translated from the article alluded to, 
contains some of Dr. O.'s observations concerning the application 
of salicylic acid to dentistry. W. T. 

In cases where the pulps of the teeth are changed through sup- 
puration and gangrene into a foul, disagreeably-smelling, gas-evol- 
ving mass, it is well known that if they are filled without first 
restoring them to a healthy condition, periostitis will in all proba- 
bility result. In such cases I introduce into the nerve canal 
salicylic acid and then make a temporary filling, which I allow to 



516 APPENDIX. 

remain for several days. In order to make the stopping more 
secure, I saturate a piece of spunk with an ethereal solution of 
salicylic acid, and with it fill the pulp chamber. The results in a 
large number of cases were good. The decaying, offensive nerves 
in the root canals become fully deodorized and shrink into a 
mumified detritus. Such detrital matter can neither by evolution 
of gas or putrid secretions irritate through the apicial foramen. I 
will here remark that it may be difficult to effectively introduce 
the dry salicylic acid into the root canals. If such be the case, we can 
have recourse with advantage to a concentrated solution of the acid 
in ether, which will volatilize in a very few moments. This course 
will be especially indicated in the molar teeth ; in the incisor teeth and 
pulp cavities where cleansing can be conveniently performed it should 
never be neglected. After washing the canals with the above solu- 
tion, we saturate a piece of spunk, place in the bottom, and then 
fill with any material that may be desirable. 

In the treatment of suppurating pulps, dry salicylic acid may be 
employed with advantage. In erosion and in inflamed conditions 
of the mucous membrane and jaws, I have applied salicylic acid 
with success. In stomatitis and scorbutic inflammation of the 
jaws, where the borders and inter-dental papillae appear degener- 
ated, gangrenous, and are coated with a putrid stringy secretion, I 
have applied salicylic acid mixed with equal parts of powdered 
cassia and cinnamon with a soft brush. The foul taste accom- 
panying such conditions, also the ill-smelling breath, soon disappear. 
It may here be added that in every inflammatory condition caused 
by roots dead or affected by periostitis, salicylic acid will prove an 
admirable remedy. 

Aside from the application of salicylic acid in special cases, I 
have employed it as an every-day means of purifying the teeth and 
mouth, with the best results. 

For a disinfecting mouth wash : One part of salicylic acid to 
three hundred parts of water will be sufficient, or if a stronger solu- 
tion is required, it may be prepared by adding three parts of phos. 
phate of soda and thirty parts of distilled water to one of salicylic 
acid. It forms a valunble addition to most tinctures and tooth 
powders. 



INDEX. 



Abrasion chemical, 38. 

Actual cautery, 310. 

Accidents in the extraction of teeth, 439. 

Adaptability, 80. 

Alveolar abcess, 343. 

treatment of, 348. 
Amalgam, 93. 
Anaesthetics, 461. 
Appendix, 475. 

Appliances for examination, 158. 
Arsenious acid, 284, 311. 

application of, 313. 
Atrophy, 31. 

Attachment of artificial crown, 365. 
Automatic plugger for engine, 499. 



Breaking the teeth, 453, 
Bur drills, 104, 113. 

Caries of the teeth, 43, 475. 

predisposing causes, 54. 

exciting causes, 59. 

consequences of, 67. 

treatment of, 70. 

comparative liability to, 65. 
Caustics, alkaline, 287. 
Chloride of zinc, 282. 
Chloroform, 464. 

Classification of cavities of decay, 218. 
Conditions to be observed in the extraction of teeth, 434. 
Congelation, 469, 



518 INDEX. 

Cohesive gold foil, 231. 

Crystal or sponge gold, 9J, 233, 210. 

Creosote and carbolic acid, 280. 

Cylinder filling, 194. 

Cobalt, 316. 

Dental periostitis, 335. , 

treatment of, 338. 
Dental caries, 43, 475. 
Denuding of the teeth, 37. 
Deposits on the teeth, 18. 

points of, 21. 
Destruction of the pulp, 305. 
Dislocation of the inferior maxilla, 457. 
Drills, 104. 
Drill stocks, 103. 

I/lectrD-magnetic mallet, 495. 

Elevators, 403. 

Ether, 461. 

Examination of decays, 157. 

Excavators, 116. 

manufacture of, 123. 
Exostosis, 34. 
Exposed pulps, 289. 

treatment of, 29 1 . 

destruction of, 305. 
Exclusion of moisture, 174. 
Extraction of teeth, 376, 410, 432. 
Extraction of roots, 419. 
Extracting instruments, 385. 
Extraction by electro-magnetism, 472. 
Extraction of the inferior incisors, 423. 

Filling instruments, 125. 
Filling teeth, 156. 

examination of, 157. 

opening cavities, 161. 

removal of decay, 163. 
Filling by classes and modifications, 220. 

with foil, 229. 
Filling large cavities on the labial surfaces of superior incisors, 269. 



INDEX. 519 



Filling pulp-cavities and canals, 318. 

Finishing fillings, 213. 

Fitting the crown, 363. 

Forming cavities, 166. 

Forming blocks, 195. 

Forceps, 391. 

Fracture of the alveolus, 451. 

General remarks on filling, 75. 
Gold, 88. 
Green tartar, 25. 

its origin, 26. 

treatment of, 28. 
Gum lancet, 406. 

Hyde's pneumatic plugger, 500. 
Heavy cutting-instruments, 101. 
Hemorrhage, 440. 

treatment of, 442. 
Hooks, 404. 

Inferior bicuspids, 425. 
Inferior cuspids, extraction of, 424. 
Inferior dens sapientise, extraction of, 43 
Inferior molars, extraction of, 427. 
Instruments for filling, 101. 
Introducing the filling, 188. 
Introducing the blocks, 198. 
Introduction, 17. 
Indications for extraction, 383. 
Irregularity of the teeth, 28. 
efi'ects of, 30. 

Laceration of the gums, 453. 
Lead for filling, 83. 



Matrices, 502. 

Manufacture of excavators. 123. 

Materials for filling, 79. 

properties of, 79. 

non-metallic, 97. 



520 INDEX. 

Metallic pivots, 370. 

Mode of using the file, 141. 

Necrosis of the teeth, 41. 

causes of, 42. 
Nitrate of silver, 280. 
Nitrous oxide, 466. 
Nitric acid, 480. 

Opening cavities, 161. 
Oxy-chloride of zinc, 96. 

Palmer's plugging instrument, 4S7. 

Pathological conditions, 372. 

Pellets for filling, 201. 

Pivot teeth, 358. 

Platinum, 86. 

Potential cautery, 31 1. 

Predisposing causes of caries, 54. 

Preparations of gold, 90. 

Preparing the teeth and roots for fill in f] 

Removal of decay, 162. 
Removal of the dens sapientise, 420. 
Removal of a wrong tooth, 454. 
Rubber-dam appliances, 179. 

Salicylic acid, 510. 

Saliva pump, 176. 

Screw, 404. 

Separation of the teeth, 145. 

Sensitive dentine, 272. 

Silver, 86. 

Superior cuspids, extraction of, 412. 

Superior bicuspids, extraction of, 414. 

Superior molars, 417. 

Syncope, 459. 

Tannin or tannic acid, 279. 
Tartar, 18. 

origin of, 19. 

points of deposit, 21. 



INDEX. 521 

Tartar, effects of, 22. 

method of removincr, 24. 
Terchloride of gold, 284. 
The key, 387. 

The method of lancing the gums, 408. 
The mallet, 205. 
The file, 138. 

use of, 141. 
The palatal portion of the crown broken away, leaving the out^r por- 
tion standing — pulp not exposed, 264. 
The clamps, 179. 
Tin, 84. 

Treatment of caries, 70. 
Treatment of exposed pulp, 291. 
Treatment of sensitive dentine, 276. 



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